WAGE ASSIGNMENT STATE OF INDIANA ) IN THE MADISON SUPERIOR COURT. ) SS: DIVISION II COUNTY OF MADISON) CAUSE NO.:48D03- Petitioner -vs- Respondent Employee Social Security Employer's Name ‘Address City” State Zip Thereby authorize you to deduct form my salary or wages, which may become due me, from my employment with you, the total sum of $ ; week/bi-weekly/semiemonthly’ (CIRCLE ONB) to distributed as follows: (Total oF AHB+C) (A) Thesum of $__ to the Clerk of this Court to be applied to my current support order. (8) Thesum of $__to the Clerk of this Court to be applied to my support arrearage. (C) The sum of $2.00 per week/bi-weekly/semi-monthly (circle one) to be retained by may employer to defray expenses incidental to this assignment. The first payment hereunder shall be made from my salary or wages aceruing in the first fi following service of this assignment upon you by mail and shall be transmitted on a Weekly, i basis thereafter until this assignment is canceled and rescinded by the Court. Dated this ___day of. 2003 Employee ORDER Pursuant to the foregoing, you are ordered to deduct from the salary or wages of the above Employee the amount set forth and to forward the same to the CLERK OF MADISON COUNTY, MADISON COUNTY GOVERNMENT CENTER, P. 0. BOX 1277, ANDERSON, IN 46016, such withholdings to be effective commencing with the first full period following receipt thereof payments are to continue on a weekly/bi-weekly/semi- ‘monthly (cirele one) basis until further order of the Court. ALL OF WHICH IS SO ORDERED this day of, 2003