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27 | Defendant | Plaintiff's attorney | |
28 | Address | Address | |
29 |
Amount of claim ______ |
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pay the defendant-employee $127.50 |
pay the defendant-employee $255.00 |
pay the defendant-employee $276.25 |
pay the defendant-employee $552.50 |
pay the defendant-employee 75% of |
the defendant-employee's disposable earnings |
pay the defendant-employee 75% of |
the defendant-employee's disposable earnings |
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pay the defendant-employee 75% of |
the defendant-employee's disposable earnings |
pay the defendant-employee 75% of |
the defendant-employee's disposable earnings |
24 | (c)Total gross earnings due for the pay period or periods covered by(b) are | $ | |
25 | (d)Average gross earnings for normal pay period as designated in (a) | $ |
28 | (1)Federal social security tax | $ |
29 | (2)Federal income tax | $ |
30 | (3)State income tax | $ |
31 | (4)Railroad retirement tax | $ |
32 | Total | $ |
34 | (f)Disposable earnings for the pay period or periods covered by (b)are (subtract (e) from (c)) | $ |
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7 | (g)I am subtracting from the disposable earnings in (f) an amountsubject to an income withholding order for support | $ | |
8 | (h)In accordance with the instructions accompanying this answerform, I have determined that the amount which may be paid to defendantis | $ | |
9 | (i)I am withholding from the amount in (h) an administrative fee inthe amount of | $ | |
10 | (j)After paying to defendant the amount stated in (h) less the ad-ministrative fee in (i), I am holding the remainder of defendant's dispos-able earnings in the amount of | $ |
14 | Available disposable earnings from (j) | $ | |
15 | Amount of claim | $ | |
16 | Difference paid to the defendant in addition to amount shown in (g) | $ |
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