1. Pay Period Frequency (select one) *

2. Enter gross amount paid to employee *

3. Enter Amounts Withheld:

a. Federal income tax *

b. F.I.C.A. (social security) *

c. Medicare *

d. State tax (including income tax, unemployment, disability) *

e. City/Local tax *

f. Health insurance premiums *

g. Involuntary retirement or pension plan payments *

a. Total Deductions (lines a-g above) =

WAGE GARNISHMENT AMOUNT COMPUTATION
Follow steps 5-7 to calculate the total garnishment amount.

5. Enter total Amounts Withheld Under Other Wage Withholding Orders with Priority. See section 2(b) of the Order. (NOTE: If the employee's wages are not subject to any withholding orders with priority, enter 0.)

6. Enter the percentage from section 2(b)(1) of the Wage Garnishment Order (may not exceed 15%). Example: If the percentage is 15%, enter .15 as a decimal.

a. Amount Equivalent to 30x the Federal Minimum Wage of $7.25 = (based on your pay frequency) 
Weekly or less = $217.50
Every other week = $435.00
2x per month = $471.25
Monthly = $942.50

c. 25% of Disposable Pay Minus Amounts Withheld Under Other Wage Withholding Orders with Priority =

NOTE: If the amount below is greater than the amounts in boxes 6.b or 6.c above, the garnishment amount is the lesser of the three.