Affidavit For Order Of Wage Garnishment Form Page 2
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4WDKy424 (Rev. 10/14) Order of Wage Garnishment (Continuous or as Designated)
U
S
D
C
NITED
TATES
ISTRICT
OURT
WESTERN
D
K
ISTRICT OF
ENTUCKY
at
Case No.
ORDER OF WAGE GARNISHMENT (CONTINUOUS OR AS DESIGNATED)
Judgment Debtor:
Date of Judgment:
Post Judgment Int Rate:
%
Judgment Creditor:
Amount of Judgment:
$
Pre-judgment Interest:
$
Garnishee (Employer):
Allowed Court Costs:
$
Amount Due:
$
To the Garnishee (Employer):
You are hereby (1) restrained from paying to the Judgment Debtor, or to anyone for him, money, property, or other
evidence of debt in your possession belonging to him or in which he has any interest; and (2) ordered to continuously
withhold and safely keep all of said nonexempt property of the Judgment Debtor until (a) the amounts due plus interest
and costs are paid in full, or (b) for only the following designated succeeding pay periods: _________.
VANESSA L. ARMSTRONG, CLERK By: _________________________ Date_______________
AFFIDAVIT AND ANSWER OF GARNISHEE (EMPLOYER)
Comes the undersigned Affiant, who after being duly sworn, states:
A. The name and Social Security Number of the Judgment Debtor ("Employee") is:
Name:________________________________________ S.S. #________________________
B. The date on which this Order was originally served was _________________________________________________
C. No funds are due employee because _________________________________________________________________
D. If no funds are withheld due to superior (earlier) garnishments, the number of those garnishments is: _____
E. The pay period of the remittance accompanying this return is from ________________ to ________________
F. The pay period of this employee is: (choose one) ( ) weekly
( ) semi-monthly
( ) monthly
1. Gross Earnings
$_____________
4. Exempt Earnings:
2. Less amounts required by law to be withheld:
(a) 75% of line 3:
$________
Federal Income Tax:
$________
(b) Other Amt (below):$________
State Income Tax:
$________
(c) Enter greater of (a) or (b):
$______________
Occupational Tax:
$________
5. Non-exempt Disposable Earnings (Line 3
Social Security:
$ ________
less Line 4(c))
$_____________
Ordered Child Support: $________
G. Remit the amount on Line 5 or the Amount Due shown
Total Deductions:
$______________
at the top of this Order plus interest and costs, whichever is
3. Disposable earnings (Gross Earnings less
less, to the Judgment Creditor or Judgement Creditor's
Total Deductions):
$______________
Attorney.
Subscribed and sworn to before me this ______ day of
______________________________________________
________________, 20__.
Affiant
Position/Title
Notary Public, State at Large ________________________
My Commission expires: __________________________
Other Amount: The other amount referred to in line 4(b). above is: (a) for weekly pay periods, 30 times the federal minimum hourly
wage; or (b) for all other pay periods, the multiple of the federal minimum hourly wage as prescribed by the U.S. Department of Labor.
Important Notice to the Judgment Debtor
The Judgment Creditor is garnishing a portion of your wages to pay a judgment entered against you in the
above court. You may have a right to recover all or part of the money your employer has withheld from your pay.
Carefully review this form and your notice of rights to assert exemption to wage garnishment you previously received.
Closely examine your employer's calculations regarding any withholding pursuant to this garnishment. If you believe
that your employer has withheld too much money from you, file your objection to this garnishment in the office of the
U.S. District Court Clerk which issued this garnishment within 13 days of the date on the payroll check you received
Note: The Clerk does not have forms.
from which money was withheld pursuant to this garnishment.
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