Form Edc-111-C - Debtor Information And Interrogatories To Employer - 2004

Download a blank fillable Form Edc-111-C - Debtor Information And Interrogatories To Employer - 2004 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Edc-111-C - Debtor Information And Interrogatories To Employer - 2004 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Use your 'Mouse' or the 'Tab' key to move through the fields, except for the "Check Boxes", then you must use the 'Mouse'.
Case ID no.: ______________________
Illinois Department of Revenue
Employer:
______________________
EDC-111-C
Debtor Information and Interrogatories to Employer
Step 1: Provide the following debtor information
1
7
Debtor’s name _________________________________________
Financial institution where you made direct deposits for this debtor
2
Debtor’s Social Security number__ __ __ __ __ __ __ __ __
______________________________________________________
3
8
Debtor’s present or last known address
Financial institution address
_____________________________________________________
______________________________________________________
Street
Street
_____________________________________________________
______________________________________________________
City
State
ZIP
City
State
ZIP
4
9
Debtor’s last known phone number ________________________
(
)
—
Debtor’s new employer____________________________________
5
10
Do you owe the debtor any funds?
Yes
No
New employer’s phone number
(
________________________
)
—
6
11
Is this the last payment you will be sending us?
Yes
No
New employer’s address
If you answered “Yes,” mark the box that best describes why this
______________________________________________________
Street
is your last payment.
This is the last payment needed to fully pay the debtor’s liability.
______________________________________________________
City
State
ZIP
As of __ __ __ __ __ __ __ __, I no longer employ this debtor.
Month
Day
Year
12
Information that may help us locate this debtor_________________
Other reason: _______________________________________
______________________________________________________
Step 2: Answer the following interrogatories
13
Write the amount of court-ordered child support that is due each week.
$___________
14
Figure the amount to withhold. See instructions.
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
Gross wages 15% of gross wages Total withheld Disposable earnings
45 times
Column D minus
Net amount due
Total amount due
minimum
Column E
(Multiply Column A
(FICA, federal tax,
(Column A minus
(
Lesser of
(Column G minus Line 13,
hourly wage
b
y 0.15)
and state tax)
Column C)
Columns B or F)
no negative figures)
wk 1 $___________ $___________ $___________ $___________ $___________ $___________ $___________
$___________
wk 2 $___________ $___________ $___________ $___________ $___________ $___________ $___________
$___________
wk 3 $___________ $___________ $___________ $___________ $___________ $___________ $___________
$___________
wk 4 $___________ $___________ $___________ $___________ $___________ $___________ $___________
$___________
wk 5 $___________ $___________ $___________ $___________ $___________ $___________ $___________
$___________
wk 6 $___________ $___________ $___________ $___________ $___________ $___________ $___________
$___________
wk 7 $___________ $___________ $___________ $___________ $___________ $___________ $___________
$___________
wk 8 $___________ $___________ $___________ $___________ $___________ $___________ $___________
$___________
wk 9 $___________ $___________ $___________ $___________ $___________ $___________ $___________
$___________
15
Add the figures in Column H. You must send us this amount.
$___________
Make your remittance payable to “Illinois Department of Public Aid.”
Step 3: Sign below
The undersigned, under oath, states that the answers to the interrogatories are true, and a completed copy of the interrogatories has been hand-delivered or
mailed first class to the address provided in Step 1 on __ __/__ __/__ __ __ __.
Month Day
Year
_______________________________________________________ Signed and sworn before me__ __/__ __/__ __ __ __.
(
)
—
Signature of employer or employer’s agent
Phone
Month
Day
Year
Mail to:
________________________________________________________
______________________________________________________
Signature of notary public
________________________________________________________
________________________________________________________
________________________________________________________
This form is authorized as outlined by the Public Act 86-1268. Disclosure of this information is
REQUIRED. Failure to provide information could result in personal liability of the employer.
This form has been approved by the Forms Management Center.
IL-492-3161
EDC-111-C (R-5/04)
RESET
PRINT

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Il-1023-c - Composite Income And Replacement Tax Return - 2004 Form Il-1023-c - Composite Income And Replacement Tax Return - 2004 Financial
Form-1a - Oklahoma Workers' Compensation Notice And Instruction To Employers And Employees Form-1a - Oklahoma Workers' Compensation Notice And Instruction To Employers And Employees Legal
Cc-form-1a - Oklahoma Workers' Compensation Notice And Instruction To Employers And Employees Cc-form-1a - Oklahoma Workers' Compensation Notice And Instruction To Employers And Employees Legal
Form Mbca-3 - Change Of Clerk And/or Registered Office 2004 Form Mbca-3 - Change Of Clerk And/or Registered Office 2004 Legal
Form 2698 - Idle Equipment, Obsolete Equipment, And Surplus Equipment Report - 2004 Form 2698 - Idle Equipment, Obsolete Equipment, And Surplus Equipment Report - 2004 Financial
Form Dr-835 - Power Of Attorney And Declaration Of Represntative - 2004 Form Dr-835 - Power Of Attorney And Declaration Of Represntative - 2004 Financial
Form 720s - Kentucky S Corporation Income And License Tax Return - 2004 Form 720s - Kentucky S Corporation Income And License Tax Return - 2004 Financial
Form Cot/st-110 - Consolidated Sales And Use Tax Schedule - 2004 Form Cot/st-110 - Consolidated Sales And Use Tax Schedule - 2004 Financial
Form Edc-111 - Response To Levy - Employer Form Edc-111 - Response To Levy - Employer Financial
Form 13586 - Additional Information And Documentation For Announcement 2004-46, Settlement Initiative - 60-day Response Form 13586 - Additional Information And Documentation For Announcement 2004-46, Settlement Initiative - 60-day Response Financial

Related Categories

Parent category: Financial
Download
Go