Payment Plan Application Page 3
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1
2
3REQUEST FOR WAGE ASSIGNMENT
First Name
MI
Last Name
Previous Names (if any)
Social Security Number
Date of Birth
Physical Address
List mailing address also if different than physical address
Street Address
City, State Zip
Home Phone
Cell Phone
Probation/Parole Officer (if any)
EMPLOYER INFORMATION
Employer
Street Address
City, State Zip
Phone
Number of hours worked per week
How often paid?
Hourly wage $
Standard deduction is $25 bi-weekly or $50 monthly and will not be filed for less
without prior approval.
I am assigning wages at the rate of $_________ per pay period (check one) weekly bi-
weekly semi-monthly monthly.
N
. N
O WAGE ASSIGNMENT IS TO BE CONSIDERED A CHANGE OF A PREVIOUS COURT ORDER
O WAGE
$100. R
ASSIGNMENT WILL BE WRITTEN ON A BALANCE LESS THAN
EDUCED PAYMENT REQUESTS
(
$50
)
MINIMUM PAYMENT OF
TOTAL MONTHLY
WILL ONLY BE GIVEN TO THOSE INDIVIDUALS WHO
/
.
PROVIDE PROOF OF INCOME AND REQUIRED BILLS
SUPPORT ORDERS IN THEIR NAME
S
____________________________
D
__________________
IGNATURE
ATE
NOTE: You need to contact the Sioux County Attorney’s Office at 712-737-2457 when:
You change jobs, addresses, or don’t see money coming out of your check(s)
You receive a letter in the mail in regards to your tickets/fine from Sioux County (please
have letter in hand when you call. We will need information from the letter in order to
help you.
Please be aware that even with a wage assignment, it is your responsibility to see that your
court obligations are paid. Watch your paystubs. If deductions are not coming out of your
paycheck within two pay periods after setting up a wage assignment, or the deductions stop,
you must contact your payroll office to see why; then notify our office. If your wage assignment
does not pay, you will become delinquent and will be subject to further action, such as
suspension of driving or registration privileges, contempt hearing, garnishment, and/or levy of
personal property.
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Parent category: Business