Free CCM 0050 5-11-09.pmd - Illinois

2821 Affidavit for Wage Deduction Summons (This form replaces CCG 0050 A) IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS MUNICIPAL DEPARTMENT/ ________________ DISTRICT

(Rev. 5/11/09) CCM 0050 A

_____________________________________________________
Plaintiff(s), v.

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Defendant(s), XXX-XX- _____________ and Respondent.

_____________________________________________________

AFFIDAVIT FOR WAGE DEDUCTION SUMMONS
I, the undersigned, certify under penalties as provided by law under 735 ILCS 5/1-109, that the following information is true. 1. I believe Respondent _____________________________________________________________________ is indebted to the Judgment Debtor __________________________________________________________________ for wages due or to become due. 2. The last known address of the Judgment Debtor is _________________________________________________________ _____________________________________________________________________________________________________________________. 3. I request that a summons issue directed to Respondent. CERTIFICATE OF ATTORNEY OR JUDGMENT CREDITOR Note: Non-Attorneys must also submit a copy of the underlying Judgment or a certification by the Clerk of the Court that entered the Judgment. 1. Judgment in this case was entered on _____________________________________, __________. 2. Amount of Judgment 3. Allowable costs previously expended: a. Initial filing fee b. Original and alias summons c. Filing and summons costs of prior supplementary proceedings 4. Filing and summons cost for this garnishment 5. Interest at 9% pursuant to statute 6. Total 7. Deduct: Total amount paid by or on behalf of the Judgment Debtor before this garnishment 8. Balance due Judgment Creditor Atty. No. _________________ Name: _________________________________________________ Attorney for: ____________________________________________ Address: ________________________________________________ City/State/Zip: ___________________________________________ Telephone: ________________________________________ FAX:__________________________________________________
DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
(OVER)

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No. ______________________________________ Court Date __________________________
(21 to 40 days after date of issuance of summons)

$ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________

Signature: ________________________________________ Attorney or Judgment Creditor Print Name: _____________________________________

(Rev. 5/11/09) CCM 0050 B
Employer/Agent: ______________________________________________________________ Court Date: ____________________ Defendant's Name: ________________________________ S.S. No. XXX-XX- _______________ Case No.: ______________________ Defendant's Address: ____________________________________________________________________________________________ CERTIFICATION OF MAILING BY JUDGMENT CREDITOR OR ATTORNEY FOR JUDGMENT CREDITOR Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure (735 ILCS 5/1-109), I certify that I mailed by regular first-class mail a copy of the Wage Deduction Notice to Defendant at the address shown above on ______________________, __________. Signature: _________________________________________________ Name: ________________________________

INTERROGATORIES/ANSWER TO WAGE DEDUCTION PROCEEDINGS Do you pay any money to the Defendant listed above? Yes No If terminated, date ____________________________, _________. IF YOUR ANSWER IS "NO," GO TO "RESPONDENT CERTIFICATION" Of the funds paid to the debtor, are any of those funds: Subject to prior court ordered deduction (including child/spouse support) Case Number, State, County __________________________________. Disability? Retirement? Otherwise exempt? (Describe

__________________________________________________________).

CALCULATION TO DETERMINE AMOUNT OF WITHHOLDING
(Note: If income varies, withholding must be recalculated for every pay period.)

Do you pay debtor: Every week Every two weeks Semi-monthly Monthly (A) Gross wages per paycheck minus mandatory contributions to pensions or retirement plan (B) 15% of (A) = (C) Enter total FICA, State Tax, Federal Tax and Medicare (D) Subtract (C) from (A) =

Other

___________________________ (A) ________________ (B) ________________ (C) ________________ (D) ________________

(E) If debtor is paid every week, enter $360.00 If debtor is paid every two weeks, enter $720.00 If debtor is paid semi-monthly, enter $780.00 If debtor is paid monthly, enter $1,560.00 If other, multiply 45 times state minimum wage (currently $8.00) times number of weeks in pay period (F) Subtract (E) from (D) (Enclose a negative number in parentheses, e.g., ($50.00)) (G) Enter the Lesser of Line (B) or (F) (H) Enter Child Support or other Court Ordered Deduction (I) Subtract (H) from (G) (Enclose a negative number in parentheses, e.g., ($50.00))

(E) ________________ (F) ________________ (G) ________________ (H) ________________ (I) _________________

IF LINE "F" IS ZERO OR A NEGATIVE NUMBER, DO NOT WITHHOLD ANY WAGES. GO TO "INSTRUCTIONS" BELOW.

LINE "I" MUST BE WITHHELD AS OF THE DATE OF SERVICE AND HELD UNTIL FURTHER COURT ORDER. IF LINE "I" IS ZERO OR A NEGATIVE NUMBER, DO NOT WITHHOLD ANY WAGES. GO TO "INSTRUCTIONS" BELOW.

(J) Subtract Employer's Statutory Fee (2% of line "I"). See 735 ILCS 5/12-814. (K) Amount to be applied to Judgment INSTRUCTIONS

(J) _________________ (K) ________________

1. Complete the Interrogatories/Answer to Wage Deduction Proceedings. 2. Complete and sign the certification at the bottom of this page. 3. Fax or mail a copy of this Answer to the Court and Plaintiff's attorney and give a copy to the Defendant. If filing in the First Municipal District, either fax it to (312) 603-6522 or mail to the Clerk of the Court, Richard J. Daley Center, 50 West Washington Street, Room 602, Chicago, Illinos 60602. To assure timely processing, the Answer should be received at least three days before the Court Date. 4. You will receive a copy by fax or mail of a Court Order instructing you how to proceed and where to send any withheld funds.

RESPONDENT CERTIFICATION Under the penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure (735 ILCS 5/1-109), the undersigned certifies that the statements set forth in this instrument are true and correct and that I have either mailed or hand delivered a copy of this completed Interrogatories/Answer to the Clerk, Plaintiff's attorney and Defendant. Address: ____________________________ Date: _______________________________ Signature of Employer/Agent: ______________________________________________ Print full name clearly: ___________________________________________________

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Telephone: __________________________ FAX: _______________________________

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS