Fill and Sign the Ca Income Form

––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– –– ––––– ––––– ––––– ––––– ––––– By ––––– CR- 119 SUPERIOR COURT OF CALIFORNIA, COUNTY OF FOR COURT USE ONLY STREET ADDRESS MAILING ADDRESS CITY AND ZIP CODE BRANCH NAME PEOPLE OF THE STATE OF CALIFORNIA V . DEFENDAN T: CASE NUMBER ORDER FOR INCOME DEDUCTION (Pen. Code, § 1202.42) TO: Employer: Addres s: Phon e: 1 . he or she pay restitution of $The court has found that the defendant has the ability to pay restitution under Penal Code section 1202.42 and has ordered that plus 10% interest. 2 . You are ordered to withhold a portion of the earnings of the defendant in this action (name): (last 4 digits of social security number (specify): I ), each pay period. 3. You are ordered to deduct: $ funds to the from the above named employee's pay each period and forward Clerk of the above entitled court Other (specify): 4. This order will terminate upon payment in full or further order of this court. Dat e: CLERK'S CERTIFICATE The foregoing is a full, true, and correct copy of the original on file in this office. SEA L CLERK OF THE SUPERIOR COURT Dat e: , Deput y Page 1 of 2 Form Approved for Optional Use Judicial Council of California CR-119 [New January 1, 2005] ORDER FOR INCOME DEDUCTION (Pen. Code, § 1202.42) Penal Code, § 1202.42el ectr onic form ã 2005 WWW.LawCA.co m L a w P u b l i s h e r s ––––– ––––– –––––PEOPLE OF THE STATE OF CALIFORNIA v. DEFENDANT: CASE NUMBER Notice to Employer re: Order for Income Deduction (Pen. Code, § 1202.42) 1 . You are required to deduct the amount specified in the Order for Income Deduction from the employee's income and to pay that amount to the clerk of the above entitled court or its agent. 2 . The order is to be implemented no later than the first payment date that occurs more than 14 days after the date of service of the order. 3 . WIthin two days after each payment date , forward the amount deducted and a statement about whether the amount totally or partially satisfies the periodic amount specified in the income deduction order. 4 . If you fail to deduct the proper amount from the employee's income, you are liable for the amount you should have deducted, plus costs, interest, and reasonable attorney fees. 5 . You may collect up to five dollars ($5) against the employee's income to reimburse you for administrative costs for the first deduction and up to one dollar ($1) for each deduction thereafter. 6 . This order and notice are binding until further notice by the court or until you no longer provide income to the employee. 7 . When you no longer provide income to the employee, you must notify the clerk of the above entitled court and provide the employee's last known address and the name and address of the employee's new employer, if known. If you violate this provision, you are subject to a civil penalty not to exceed two hundred fifty dollars ($250) for the first violation or five hundred dollars ($500) for any subsequent violation. 8 . You must not discharge, refuse to employ, or take disciplinary action against the employee because of an income deduction order. If you violate this provision, you are subject to a civil penalty not to exceed two hundred fifty dollars ($250) for the first violation or five hundred dollars ($500) for any subsequent violation. 9 . If you receive income deduction orders for two or more employees sent by the same court, you may combine the amounts that are to be paid in a single payment, but you must identify the portion of the payment that is attributable to each employee. 10. If you receive two or more income deduction orders against the same employee, you must contact the above entitled court for further instructions. CR-119 [New January 1, 2005] ORDER FOR INCOME DEDUCTION (Pen. Code, § 1202.42) Page 2 of 2el ectr onic form ã 2005 WWW.LawCA.co m L a w P u b l i s h e r s