Illinois > Local County > Champaign > Civil
Affidavit For Wage Deduction Order - Illinois
| Affidavit For Wage Deduction Order Form. This is a Illinois form and can be used in Civil Champaign Local County . |
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CIRCUIT COURT OF ILLINOIS Sixth Judicial Circuit Champaign County _______________________________ Petitioner vs. _______________________________ Respondent and _______________________________ Employer Case No:______________________________ Return date _____________________________ (21 to 40 days after issuance) AFFIDAVIT FOR WAGE DEDUCTION ORDER __________________________________________________ certifies that the following information is true and correct under the penalties as provided by Section 1-109 (perjury): 1. Judgment was entered in this case on ___________________________________________________________, 20___, in favor of (Date) Petitioner ___________________________________________________________________________________________ and against Respondent __________________________________________________________________________________________________ for $__________________________ and costs. $__________________________ has been paid on the Judgment. There is unpaid on the Judgment $___________________________ principal $ __________________________ costs $___________________________ interest $___________________________ TOTAL I believe the Employer, ______________________________________________________________________________________, is or will be indebted to the Respondent for wages due or to become due. The last known address of the Respondent is: ___________________________________________________________________ ______________________________________________________________________________________________________________. 2. 3. 4. 5. I request that a Wage Deduction Summons be issued and directed to the Employer: __________________________________________________ (Signature) __________________________________________________ (Date) I certify that Judgment was entered as stated in paragraph 1 above, and the Wage Deduction Notice has been mailed to the Respondent by first class mail at the Respondent's last known address. ________________________________________ Petitioner or Petitioner's Attorney Name:_________________________________________________________ Petitioner's Attorney or Petitioner (if he/she is not represented by an Attorney) Name: or Petitioner's Attorney:_______________________________ Petitioner Attorney for: Address:_______________________________________________________ Address: City/State/Zip Code:____________________________________________ City/State/Zip: Telephone: _____________________________________________________ Telephone: Note: FOUR (4) COPIES OF THIS AFFIDAVIT MUST BE SERVED ON THE EMPLOYER. Interrogatories to Employer Wage Deduction is to be filed on or before the return date as shown on this Affidavit and/or Summons. CERTIFICATE OF PETITIONER OR PETITIONER'S ATTORNEY Page 1 of 1 - Affidavit for Wage Deduction Order Revised: 12/12 Revised: 01/09 Katie Judicial Circuit Court Clerk of the Sixth M. Blakeman Clerk of the 101 E. Main Street Sixth Judicial Circuit Court Urbana, Illinois 61801 White-Circuit Clerk Canary-Employer Linda S. Frank 101 E. Main Street Pink-Petitioner Urbana, Illinois 61801 Goldenrod-Respondent American LegalNet, Inc. www.FormsWorkFlow.com CIRCUIT COURT OF ILLINOIS Sixth Judicial Circuit Champaign County _______________________________ Petitioner vs. _______________________________ Respondent Case No: ____________________ Case No:______________________ Respondent's Soc. Sec. No:______________________ INTERROGATORIES TO EMPLOYER - WAGE DEDUCTION Employer/Agent: __________________________ certifies under penalty of perjury that the following answers are true and correct to the best of her/his knowledge and belief concerning the property of the Respondent: DO YOU PAY MONIES TO THE RESPONDENT LISTED ABOVE: YES NO If Respondent is no longer employed by you, please give termination date: _____________________________________ STATE WHETHER ANY FUNDS paid to Respondent are for disability, retirement or are in any other way exempt or subject to another court order (Examples: Child support, lien by Federal Government): ____________________________________________ ONE PAY PERIOD EQUALS: __________day(s) __________week(s) __________bi-monthly ___________month ___________other WITHHOLDING You are required by law to withhold the lesser of (1) 15% per week of the gross amount paid the employee named herein for any work week; or (2) the amount by which disposable earnings of said employee for a week exceed forty-five times the minimum hourly wage in effect at the time the amounts are payable (Example: the 2010 minimum wage of $8.25 per hour; 45 x 8.25 = $371.25). On a Wage Deduction Order, the employer is entitled to $12 once per proceeding (not per payroll) fee or 2% of the sums withheld. NOTICE TO EMPLOYER - You must complete and return these Interrogatories. The original is sent back to the Circuit Clerk; you must mail a copy to the Petitioner or his/her attorney; you should give a copy to the Respondent; and you should keep a copy for yourself. YOU MUST FILE YOUR ANSWER EVEN IF THE RESPONDENT IS NO LONGER EMPLOYED BY YOU. THE ANSWER MUST BE FILED ON OR BEFORE THE DATE ON THE SUMMONS. UPON RECEIPT OF THE WITHHOLDING ORDER, ANY MONEY WITHHELD IS SENT TO THE PETITIONER'S ATTORNEY OR, IF NONE, THE PETITIONER DIRECTLY. (DO NOT SEND ANY OF THE WITHHELD MONEY TO THE CLERK OF THE CIRCUIT COURT. HOW TO CALCULATE THE AMOUNT OF WAGES TO WITHHOLD: _________________________________________________________________________________________________________ A Gross Wages, minus mandatory contributions to pensions or retirement plan$ A _________________________________________________________________________________________________________ B Enter total of FICA, Medicare, Federal Tax, and State Tax $ B _________________________________________________________________________________________________________ C Subtract Line B from Line A (This is net pay) $ C _________________________________________________________________________________________________________ D Enter If paid every week $ 371.25 $ D ______________________________________________________________________________ amount of If paid every 2 weeks $ 742.50 ______________________________________________________________________________ Exempt Wages ______________________________________________________________________________ If paid twice a month $ 804.38 If paid every month $1608.75 ____________________________________________________________________________________________________
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