FO RM H-4 Page 1 of 2 UNITED STATES DISTRICT COURT UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF WEST VIRGINIA In re Case No. Chapter Debtor(s), Plaintiff(s), v. A.P. Defendant(s), v. Employer. AFFIDAVIT FOR SUGGESTEE EXECUTION This day personally appeared before the undersigned authority, ______________________________________, who after being first duly sworn, says that _____________________________________________________ secured a judgment against _________________________________ of ________________________________________ in the sum of $__________________ and costs of $__________________ on the _____ day of _________________, 20___. The undersigned further states upon oath that since the date of judgment payments in the total sum of $_____________________ have been applied to said judgment and that there is still due and unpaid the sum of $_______________, together with interest at the rate of _________________% on the principal sum from the date of judgment. (Continued on Next Page) American LegalNet, Inc. www.FormsWorkFlow.com FO RM H-4 Page 2 of 2 The undersigned further states that the Defendant, _______________________________, is employed by ____________________ at __________________________________________ and that he believes that the weekly disposable earnings in excess of thirty times the federal minimum hourly wage in effect at the time the earnings were payable are now, or will hereafter, within one year from this date, become due to the judgment debtor. _________________________________________ Affiant Taken, sworn, and subscribed before me, the undersigned authority, this the _____ day of _________________________, 20____. __________________________________________ United States Bankruptcy Clerk or __________________________________________ Notary Public My commission expires: _______________________________ American LegalNet, Inc. www.FormsWorkFlow.com