For Official Use COUNTY STATE OF WISCONSIN, CIRCUIT COURT, IN THE MATTER OF THE OUTSTANDING OBLIGATIONS OF: Income Assignment Order for Unpaid Fines and Other Financial Penalties Debtor Case No(s). Date of Birth THE COURT FINDS: 1. The debtor has been ordered by the court to pay fines, forfeitures, restitution, or other court obligations. The , plus interest of $ obligation has not been timely paid and the amount owed is $ and any future accruing interest. The entry of an assignment will not cause the debtor irreparable harm and an assignment should be ordered. 2. The address of the debtor is: Address: City/State/Zip Code: Telephone Number: 3. The name and address of the debtor’s employer(s) or payor is: Name(s): Address: City/State/Zip Code: Telephone Number: THE COURT ORDERS: 1. You as the employer or other person owing any of the following to the debtor: • commissions, • earnings, • salaries, • wages, • pension benefits, • benefits under ch. 102 (worker’s compensation), • or other money due or to be due the defendant in the future, shall pay those monies to the clerk of court for this county until the total amount due has been paid or further order of the court. , , per (frequency) % of gross income or $ 2. You shall withhold . No more than 25% of the debtor’s disposable income may be withheld unless the to commence on debtor agrees to have the full amount withheld. Disposable income means the debtor’s earnings after deducting social security taxes and federal and state income taxes listed on a debtor’s wage statement. This order shall take priority over all other income withholding orders, garnishments, and voluntary wage assignments with the exception of: • any child/family support, maintenance, and orders for health insurance coverage for children; • orders issued by any court under chapter 13 of Title 11; or • any debt due for any state or federal taxes. If, for each payment under this order, 25% or more of the debtor’s disposable earnings are being withheld by the employer/payor under an order for child/family support, no funds may be withheld under this order. Within five days after each day on which the employer pays money to the defendant, the employer shall send the amount withheld to the clerk of circuit court that provided notice of income assignment. GF-161, 04/09 Income Assignment Order for Unpaid Fines and Other Financial Penalties §§778.30, 812.30(6), 973.05(4)(b), 973.05(5)(c), Wisconsin Statutes Federal Consumer Protection Act, 15 USC 1973 This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Income Assignment Order for Unpaid Fines and Other Financial Penalties Page 2 of 2 Case No(s). 3. You shall remit payment to: 4. You may deduct and retain necessary disbursements not to exceed $3.00 for each payment to comply with this order. 5. If you have already received and are collecting on another assignment for unpaid fines and other obligations from this or another court, then: • Check the box below indicating you have received other assignment(s). • Sign, date, and return a COPY of this form to the clerk of courts of this county within 10 days of receiving this notice. • Keep the original of this form and when the prior assignment(s) are paid in full, begin making the payments required by this assignment until the total amount due under this assignment is fully paid. 6. You shall notify the clerk of courts within ten days after the employee is temporarily or permanently not being paid. Notice to court that another assignment(s) has been received. I am the employer of the debtor and: • have received and am now paying on another assignment for fines and other court obligations of the debtor; • understand that I am to return a copy of this form to the clerk of court of this county within 10 days of receiving this assignment; and • understand that I will retain this assignment and once any other earlier assignment(s) is paid in full, I will then pay this assignment. Signature of Employer Date BY THE COURT: Distribution: 1. Original - Clerk of Court 2. Employer/Payor 3. Debtor Circuit Court Judge Name Printed or Typed Date GF-161, 04/09 Income Assignment Order for Unpaid Fines and Other Financial Penalties §§778.30, 812.30(6), 973.05(4)(b), 973.05(5)(c), Wisconsin Statutes Federal Consumer Protection Act, 15 USC 1973 This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com