Voluntary Wage Assignment - Defendants On Track

Voluntary Wage Assignment

Personal Information

First Name

Middle Name

Last Name

SSN

Address

Apartment, suite, etc.

City

State

Zip

Phone

Email

Employer Information

Employer Name

Address

Apartment, suite, etc.

City

State

Zip

Phone

Wage Information

I am assigning wages at the rate of $120.00 per month to the Clerk of Court. My employer may deduct equal amounts from each paycheck I receive in a month, as long as the total deducted per month equals the above stated amount. The minimum deduction for wage assignments is $120.00 monthly. Any other arrangements must be approved by the County Attorney’s office.

Signature

Signature Date

Date of Birth