Form Edc-111 - Response To Levy - Employer
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Illinois Department of Revenue
Taxpayer ID (SSN): __ __ __ - __ __ - __ __ __ __
EDC-111
Response to Levy - Employer
Employer name : ______________
Step 1: Provide the following debtor information
1
Debtor’s name ________________________________________
5
Information that may help us locate this debtor.
2
Debtor’s present or last know phone number and address
___________________________________________________
_____) _____-______ _______________________________
(
6
Determine if your payments to the debtor are exempt from this
Phone number
Street
levy. Are your payments any of the following:
___________________ _______________________________
City
State
ZIP
to the debtor who is currently under bankruptcy protection.
3
Do you pay the debtor any wages, salary, or other compensation?
Write bankruptcy number and court. _________________________
Yes. If yes, continue to Line 4.
to the debtor who is an offi cer, employee, elected offi cial of any state
No. If no, complete one of the following lines and skip to Step 3.
other than Illinois.
As of __ __ /__ __ / __ __ __ __, I no longer employ this debtor.
wages to “seamen” as defi ned in federal law 46 U.S.C. 10101.
Month
Day
Year
Other reason: ___________________________________
pension and retirement benefi ts.
4
Financial institution for direct deposit to debtor, if applicable.
7
Did you mark any box in Line 6?
___________________________________________________
Yes. If yes, skip to Step 3. Your payments are exempt.
___________________________________________________
No. If no, continue to Step 2.
City
State
ZIP
Step 2: If you pay the debtor funds, complete this section
8
If you are fi rst required to withhold child support, write the amount of court-ordered child support that was due each
week.
$ ___________
9
Complete Columns A - H each week to determine the levy amount to withhold.
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
Write the amount
Multiply
Write the total
Subtract
Multiply Illinois
Subtract
Compare Column
Subtract Line 8
of gross
Column A
amount of
Column C from
minimum hourly
Column E from
B and F; write the
(amount above)
weekly wages
by 15% (0.15)
FICA, federal tax,
Column A
wage by 45
Column D
smaller amount
from Column G
and state tax
(if negative, write
required to be
“0”)
withheld
wk 1 $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________
wk 2 $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________
wk 3 $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________
wk 4 $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________
wk 5 $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________
10
Total Column H and write the amount. Make your remittance payable to “Illinois Department of Revenue.”
On your payment, write the Debtor’s name and Taxpayer ID. Mail levy payment and a copy of Form EDC-111 with each levy payment until
the balance of the levy is fully paid.
•
Your fi rst levy payment is due at the close of your current payroll period.
•
Additional levy payments are due to us at least once every two months.
11
Is this the last payment you will be sending us?
Yes
No
Step 3: Sign below - Employer
I certify, under oath, that the above information is true to the best of my knowledge, and that a completed copy of this form has been hand-delivered or mailed
fi rst class to the debtor at the address provided in Line 2 on __ __ / __ __ / __ __ __ __ .
Month
Day
Year
______________________________________ (____) ___________
Signature of employer or designated agent
Phone number
Mail completed form to:
_______________________________________________________
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19035
Employer name
SPRINGFIELD IL 62794-9035
_______________________________________________________
Employer address
This form is authorized as outlined by Public Act 86-1268. Disclosure of this information is
REQUIRED. Failure to provide information could result in personal liability of the employer.
EDC-111 (R-3/12)
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