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Our Account Number (listed on the letter)

Employer Name

Employee Name

First Name

Last Name

Date Garnishment Order Received

YYYY

Is the Employee Still employed with your company?

If the employee is no longer employed, what was the employee's last date of employment?

YYYY

Is the garnishment order referenced above currently in place and active?

If the garnishment order is still in place and active, are there withholdings currently being withheld from the employees pay?

Please list the last date funds were withheld from the employees earnings.

YYYY

Amount of funds that were last withheld from the employee's earnings

If funds have not been withheld from the employee's earnings, when is the expected first date of withholding?

YYYY

If the garnishment order is not currently active and in place, please describe the reason(s) for which the employee's earnings are not subject to this garnishment order.

Payroll Contact Name

Payroll Contact Phone number

Payroll Contact Email

Garnishments

Special Counsel Andy Bowers