Fill and Sign the State of Delaware Office of State Court Collections Form

Assignment of Wages Employer:RE:Employee (Defendant): Def Name Social Security Number: Def SSN To Whom it May Concern: The subject employee is indebted to the State of Delaware in the sum of $Total Monies Owed for fines, court costs and/or restitution. At the bottom of this form is an executed authorization by the employee for the deductions from the employee’s wages. You are therefore directed, under the provision of 11 Del. Code §4104c, to withhold $ Weekly deduction weekly from the wages of Def Name (Employee) until the total sum of $ Total Monies Owed has been deducted. Please forward that amount on a weekly, biweekly or monthly basis to the “State of Delaware” at one of the above referenced locations. 11 Del. Code §4104c also provides that an employer shall take no action against an employee who has executed an assignment of wages, and that the employer may not penalize that employee solely because of the assignment. Attention: Payments are due on a regular basis. If payments are not received, a Contempt of Court Hearing will be scheduled immediately. Should the individual leave your employ, or you require any additional information, please contact the above referenced Office of State Court Collections Enforcement. CC: ProthonotaryRevised: 10/15/15 Criminal Action NumberCourt/County CRA#Defendant ID Number Def ID # Company NameCompany Street AddressCity, State ZipAttn: Payroll Dept. Voluntary Assignment of Wages I Def Name, do hereby agree to make payments to the State of Delaware, Office of State Court Collections Enforcement in the amount of $Weekly deduction weekly beginning 8/14/2019 on account(s) # CRA # until the account(s) is/are paid in full. Defendant Name:Def NameDefendant Address:Def Street Name City, State Zip Defendant Phone #:Home PhoneDate: 8/14/2019 Defendant Signature: State of Delaware Office of State Court Collections 414 Federal St, Rm 175 Dover, DE 19901 (302) 739-1980