IN THE IOWA DISTRICT COURT IN AND FOR BUENA VISTA COUNTY
STATE OF IOWA, No.
v. VOLUNTARY WAGE
Now on this ____ day of _______ 2012, the defendant has entered into a Voluntary Wage
Assignment Agreement regarding the method of payment of Defendant’s financial obligations herein.
The Defendant has agreed that his income should be assigned to the Clerk of Court in and for
Buena Vista County until all of Defendant’s obligations are paid in full. Defendant’s income should be
assigned to the Buena Vista County Clerk of Court at the rate of $______ per check and shall be
deducted from his wages due and to become due from his employer. At least monthly, the employer shall
transmit a check for that amount to the Clerk of District Court, Buena Vista County Court House, P.O. Box
1186 Storm Lake, Iowa 50588. The employer shall notify the Buena Vista County Attorney’s Office at
712-732-1933 if the Defendant terminates employment.
This wage assignment results from collection of fines and costs initiated by the Buena Vista
County Attorney’s Office pursuant to Iowa Code Section 331.756(5) and 909 and shall remain in effect
until the debt has been paid. State of Iowa procedures to intercept any State Income Tax Refund due the
defendant based upon unpaid financial court ordered obligations are not affected by this payment plan.
Defendant (Please print) Address (City, State & Zip Code)
Home Phone Work Phone Cellular Phone Alternate Phone
Signature Social Security Number Date of Birth
Complete blanks below for ASSIGNMENT OF WAGES:
CITY, STATE & ZIP