The employer is hereby awarded compensation pursuant to I.C. 24-4.5-5-105(4) in the sum of $ (the greater of $12.00 or 3% of the total amount required to be deducted hereunder). The employer may collect such fee in equal portions of not less than $1.00 (except that the final portion shall be the balance), by retaining such amounts over the number of pay periods during which deductions are required. Said compensation shall be paid as follows: One-half of the fee to be paid by the debtor by the employer increasing the judgment by the appropriate amount and one-half of the fee to be paid by the creditor by the employer withholding said amount.

SO ORDERED this day of , .

**Disposable earnings: That portion of a person’s income which he/she is free to spend or invest as he/she sees fit after payment of taxes and other obligations.

Distribution: