STATE OF INDIANA )
) SS:
COUNTY OF DELAWARE )
IN THE DELAWARE CIRCUIT COURT NO.
Plaintiff
vs.
Defendant
CAUSE NO. 18C0
Garnishee Defendant (Employer)
VOLUNTARY WAGE ASSIGNMENT
SSN # XXX-XX-

Comes now the defendant, , and voluntarily submits to a deduction from salary and wages which may become due to him/her from his/her employment at in the total sum of $ (Balance of Judgment), plus interest and/or costs. Said sum is to be paid as follows:

  • 1. The sum of $2.00 may be retained by his/her employer to defray expenses incident to this assignment should his/her employer elect to retain such amount for this service.
  • 2. The sum of $ to be deducted each pay and mailed to the Clerk of Delaware County. Payments to be mailed to DELAWARE COUNTY CLERK, P. O. Box 1089, Muncie, IN 47308.
  • 3. The first payment hereunder shall be made from salary or wages accruing in the first full payroll period following service of this assignment and shall be transmitted on a weekly or bi-weekly basis thereafter until this assignment is canceled or rescinded by this Court.
DATED:
Signature
EMPLOYER: PLEASE SEND PAYOR CAUSE NUMBER WITH EACH REMITTANCE