Fill and Sign the Proposal Procedures and Requirements Wisconsin Form

GF-161, 08/05 Income Assignment Order for Unpaid Fines and Other Financial Penalties §§778.30, 973.05(4)(b), 973.05(5)(c), Wisconsin Statutes Federal Consumer Protection Act, 15 USC 1973 This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF THE OUTSTANDING OBLIGATIONS OF: Debtor Income Assignment Order for Unpaid Fines and Other Financial Penalties Social Security Number Case No(s). For Official Use THE COURT FINDS: 1. The debtor has been ordered by the court to pay fines, forfeitures, restitution, or other court obligations. The obligation has not been timely paid and the amount owed is $ . The entry of an assignment will not cause the debtor irreparable harm and an assignment should be ordered. 2. The address of the debtor is: Address: City/State/Zip Code: Telephone Number: 3. The name and address of the debtor’s employer(s) or payor is: Name(s): Address: City/State/Zip Code: Telephone Number: THE COURT ORDERS: 1. You as the employer or other person owing any of the following to the debtor: • commissions, • earnings, • salaries, • wages, • pension benefits, • benefits under ch. 102 (worker’s compensation), • or other money due or to be due the defendant in the future, shall pay those monies to the clerk of court for this county until the total amount due has been paid or further order of the court. 2. You shall withhold % or $ , per (frequency) , to commence on . No more than 25% of the debtor’s disposable income may be withheld unless the debtor agrees to have the full amount withheld. This order shall take priority over all other income withholding orders, garnishments, and voluntary wage assignments with the exception of: • any child/family support, maintenance, and orders for health insurance coverage for children; • orders issued by any court under chapter 13 of Title 11; or • any debt due for any state or federal taxes. If, for each payment under this order, 25% or more of the debtor’s disposable earnings are being withheld by the employer/payor under an order for child/family support, no funds may be withheld under this order. 3. Remit payment to: Income Assignment Order for Unpaid Fines and Other Financial Penalties Page 2 of 2 Case No(s). GF-161 08/05 Income Assignment Order for Unpaid Fines and Other Financial Penalties §§778.30, 973.05(4)(b), 973.05(5)(c), Wisconsin Statutes Federal Consumer Protection Act, 15 USC 1973 This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 4. You may deduct and retain necessary disbursements not to exceed $3.00 for each payment to comply with this order. 5. If you have already received and are collecting on another assignment for unpaid fines and other obligations from this or another court, then: • Check the box below indicating you have received other assignment(s). • Sign, date, and return a COPY of this form to the clerk of courts of this county within 10 days of receiving this notice. • Keep the original of this form and when the prior assignment(s) are paid in full, begin making the payments required by this assignment until the total amount due under this assignment is fully paid. Notice to court that another assignment(s) has been received. I am the employer of the debtor and: • have received and am now paying on another assignment for fines and other court obligations of the debtor; • understand that I am to return a copy of this form to the clerk of court of this county within 10 days of receiving this assignment; and • understand that I will retain this assignment and once any other earlier assignment(s) is paid in full, I will then pay this assignment. Signature of Employer Date BY THE COURT: Circuit Court Judge Name Printed or Typed Distribution: 1. Clerk of Court (original) 2. Employer/Payor 3. Debtor Date