2. Wage Attachment

4. Name*
5. SSN*
6. Date of Birth*
   Date of Birth
8. Case Number
10. Employer*
11. Employer Address*
13. Amount Deducted Monthly*
14. Amount Owed Total
16. By checking this box you acknowledge that the sum deducted is to be sent to Dan Byrnes, Clerk of Courts, 45 N. George Street, York, PA 17401 and is to be applied to my account. I understand that I am solely responsible to ensure that payments are deducted and submitted properly. Checks should be made payable to Clerk of Courts. *

18. 
    Once submitted, the form will be printed and mailed to your employer, who will then complete the section below.

    I/WE, __________________________(Company Name), do hereby agree, so long as said defendant shall be employed by us, to deduct and remit the aforesaid sum.
    
    Employer’s Representative _________________________________________________
    Title _________________________________________________
    Witness: _____________________________________
    Dated: _____________________________________ 

Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field