Fill and Sign the Plaintiffcreditor Form

PLAINTIFF/CREDITOR:DEFENDANT/JUDGMENT DEBTORStreet: ____________________________________ Street: ____________________________________City/State/Zip: _____________________________ City/State/Zip: _____________________________Phone: ___________________________________ Phone: ___________________________________GARNISHEE: ATTORNEY OR REPRESENTATIVE:Street: ____________________________________ Street: ____________________________________City/State/Zip: _____________________________ City/State/Zip: _____________________________Phone:___________________________________ Phone: ___________________________________CASE NUMBER: _____________________________________________ GARNISHEE'S NON-EXEMPT EARNINGS STATEMENT (TAX JUDGMENT) PAY PERIOD _________________ to ________________ Judgment debtor employed now? [ ] Yes [ ] NoIf no, what was the last date. for which earnings were owed? ___________________________________Instructions: You are required to withhold a portion of judgment debtor's disposable earnings. To determine the amount to withhold, complete the calculations below and sign and date this form at the bottom. A copy of this statement and a hearing request form must accompany each payment to judgment debtor and creditor. You are entitled to a $5.00 fee for completing this form.Gross earnings (1) $___________________Disposable earnings (gross minus deductions required by law) (2) $__________________Amount withheld pursuant to other garnishment or courtordered assignment for collection of support of a person (3) $__________________Amount withheld pursuant to earlier garnishment or levythat was not for support of a person (4) $_________________Add lines (3) and (4) (5) $_________________Subtract line (5) from line (2) and enter balance, less $5.00 fee (6) $_________________This is the amount you withhold and send to creditor.Date: ____________________________ __________________________________________ Garnishee FILED BY: __________________________________________FIRM: ______________________________________________BAR NUMBER (IF APPLICABLE): _____________________ADDRESS: __________________________________________PHONE: ____________________________________________REPRESENTING: ____________________________________