Free CCM 0050 6-30-08.pmd - Illinois

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

(Rev. 6/30/08) CCM 0050 A

Print Name of Person or Party Suing _____________________________________________________
Plaintiff(s), v.

Print Name of Person or Party Being Sued _____________________________________________________
Defendant(s), XXX-XX- _____________ and Respondent.

Print name of Respondent _____________________________________________________

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Print Your Case Number No. ______________________________________
Print Return Date Court Date __________________________
(21 to 40 days after date of issuance of summons)

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.

Print Name of Person Owing Judgement Judgment Debtor __________________________________________________________________ for wages due or to become due.
_____________________________________________________________________________________________________________________. 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 a. Initial filing fee

Print Complete Address of Person Owing Judgment 2. The last known address of the Judgment Debtor is _________________________________________________________

EX AM

PL E

Print name of Respondent 1. I believe Respondent _____________________________________________________________________ is indebted to the

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

3. Allowable costs previously expended: 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

Print "Pro Se-99500" If No Attorney Atty. No. _________________ Print Your Name Name: _________________________________________________ If No Attorney, Leave Blank Attorney for: ____________________________________________
Print Your Address Address: ________________________________________________

Signature: ________________________________________ Attorney or Judgment Creditor Print Name: _____________________________________

Print City, State and Zip Code City/State/Zip: ___________________________________________
Print Complete # Telephone: ________________________________________

Print Complete # FAX:__________________________________________________
DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

(OVER)