GF-161A, 08/12 Income Assignment Order for Unpaid Fines and Other Financial Obligations Federal Consumer Protection Act, 15 USC 1973 247247778.30, 812.30(6), 973.05(5)(c), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF THE OUTSTANDING OBLIGATIONS OF Debtor Date of Birth Income Assignment Order for Unpaid Fines and Other Financial Obligations Case No(s). THE COURT FINDS: 1. The debtor has been ordered by the court to pay fines, forfeitures, restitution, or other court obligations. The obligation has not been timely paid and the amount owed is $ , plus interest of $ and any future accruing interest. 2. The address of the debtor is Address: City/State/Zip Code: Telephone Number: 3. The name and address of the d 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 Chapter 102 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. 2. You shall withhold % of gross income or $ , per [frequency] , to commence on [Date] debtor agr American LegalNet, Inc. www.FormsWorkFlow.com GF-161A, 08/12 Income Assignment Order for Unpaid Fines and Other Financial Obligations Federal Consumer Protection Act, 15 USC 1973 247247778.30, 812.30(6), 973.05(5)(c), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 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. employer/payor under an order for child/family support, no funds may be withheld under this order. Within five (5) 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. 3. You shall remit payment to [Name and Address] 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 use court form GF-161B to notify the court that you have received other assignment(s); sign, date, and return a COPY of form GF-161B to the clerk of courts of this county within ten (10) days of receiving this notice; and keep the original of the 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. Form GF-161B can be downloaded from https://www.wicourts.gov/forms1/circuit/index.htm or obtained by calling the clerk of circuit court. 6. You shall notify the clerk of courts within ten days after the employee is temporarily or permanently not being paid. DISTRIBUTION: 1. Clerk of Court 2. Employer/Payor 3. Debtor NOTICE TO DEBTOR: If you believe the balance is incorrect or t he income assignment will cause irreparable harm, you must file a written objection with the court. American LegalNet, Inc. www.FormsWorkFlow.com