Preview
WAGE EXECUTION PROCEEDINGS: STATE OF CONNECTICUT
APPLICATION, ORDER, EXECUTION SUPERIOR COURT
JD-CV-3 Rev. 2-15 www.jud:ct.gov
ca:
29 U.S.C. 206(a)(1)
1.
2.
3.
4,
S. §§ 31-58()), 52-350a, 52-361a, 52-: ‘356d,
SS aa Employer: See Page 2 for instructions
Instructions
Clerk
1. Issue execution by signing original,
2. Enter any court ordered limitation at the bottom of 2.
section Il on page 2.
Judgment Creditor or Attorney
Unless filing electronically, prepare original and four copies.
Attach form JD-CV-3a to this form, or include with execution
as one PDF electronic form.
Present original and 3 copies to clerk of court. 3. Return original and 2 copies if on paper.
Keep one copy for your file. 4, Retain/scan copy for court file,
Name and mailing address of Judgment Creditor or Attomey
y
APPWEX
INC
WAGEEX
IRR
Proper Officer
ee
- Leave one signed copy with employer.
Make return on signed original.
Leave one copy of Modification and Exemption
Claim form (JD-CV-3a) with employer and fill in
“Date of Service" on form.
- (To be completed by Judgment Creditor or Attomey) 4 ADA NOTICE
The Judicial Branch of the State
MIDLAND FUNDING LLC ‘of Connecticut complies with the Americans
with Disabilities Act (ADA). If you need a
C/O London & London reasonable accommadation in accordance
5 te with the ADA, contact a court clerk or an ADA
48 Christian Lane contact person listed at www.jud.ct.gow/ADA.
Newington, CT 06111 1417-14987
a]
‘Address of court (Number, street, and town) GA. ID. Housing Session | Date of judgment | Docket number =
(Fol) 155 CHURCH ST PUTNAM CT 06260 07-Nov-17 WWM-CV-17-5007598-S
— Name(s) and address(es) of Judgment Creditor(s) Name(s) and address(es) of Judgment Debior(s)
MIDLAND FUNDING LLC Matthew Barks
C/O London & London
48 Christian Lane | 524 Providence Pike
§ Newington, CT 06111 Putnam CT 06260
[Name and address of employer of Judgment Debtor (known) 2447 ware Rd “Telephone number of employer (i knowny
3
+= [Westview Commons Dayville CT 06241 860/428-2230
‘& FT Amount of judgment (Include where applicable, prejudgment interest and alfomey’s fees) ‘2. Amount of costs and fees —
+ | 624.68 100.95
3. Total amount of judgment, costs and fees (Add 7 and 2) Total amount paid (any “I ‘5 400805. Russell L. London | 06/07/2022 860-666-4500
To: Any Proper Officer
By the authority of the State of Connecticut, you are ordered to cause any wages due to the Judgment
Debtor(s), not exceeding the Amount of Execution calculated on page 2, to be paid to the Judgment
Creditor(s) until the judgment is satisfied, including postjudgment interest as ordered by the court, if
applicable, plus t lication fee(s) and other Court ordered postjudgment costs and fees, and your own
fees or until theexecutidn is modified or set aside.
Serve this eyécution wihin one year of this, date poe return of service to this courtwithin thirty days
Page 1 of 2
‘WAGE EXECUTION PROCEEDINGSImportant Notice To Employer
17-14987
You are being served with a wage execution, a court order requiring you to withhold non-exempt wages from a person employéd by you. This execution is being served on you
because your employee, the Judgment Debtor (on page 1), has had a judgment entered against him/her by the Superior Court requiring him/her to pay judgment, costs and fees to
the Judgment Creditor (6n page 1) and has not made payment of the total amount of the judgment plus any costs and fees as shown on page 1. This notice is to inform you of the
actions you must take in order to comply with the law regarding wage executions. Please read each section carefully.
|. You must notify the employee — Your employee has certain legal rights which
may allow him/her to request the court to change or stop this execution upon his/her
wages. A notice of his/her rights and how to get a hearing in court is attached to the
second copy of the wage execution given to you by the officer. You must complete
your portion of the wage execution and your portion of the exemption and modification
claim form arid deliver or mail, postage prepaid, a copy of these papers to your
employee immediately so that your employee can make any claims allowed by law.
1, Execution not effective for 20 days — This execution is not effective until after
20 days from the day the officer served these papers.on you. No money should be
deducted from your employee's wages until the first wages you pay to your employee
after the 20-day period ends. If your employee elects within the 20-day period to
make a claim to the court that his/her wages are partially or totally exempt from
to pay this judgment or he/she seeks to have the amount of this execution
changed, wages are not ta be withheld fram the employee until the court decides the
claims or determines the rights of your employee in this.case. If you are not notified
that your employee has filed papers with the court, the execution is to be enforced
after 20 days from the date of service on you,
IL Stay of execution — No earings clairied to be exempt or subject to a claim for
modification may be withheld from any employee unt determination of the claim by
the court.
IV. Only one execution issued under section 52-36ta of the General Statutes is,
to be satisfied at a time — You must make deductions from your employee's wages
and pay over the withheld money against only one execution issued under General
Statutes section $2-361a at a time. If you are served with more than one execution
issued under General Statutes section §2-364a against this employee's wages, the
executions are to be satisfied in the order in which you are. served with them. (Income
withholdings and voluntary wage deductions for support of a family, # there are any,
must be paid before this execution. Family support income withholdings and voluntary
wage deductions are issued on Form JD-FIM-1,)
V. Maximum amount deducted — The maximum amount which ean be legally
withheld from your employee's wages is 25% of hishher disposable eamings for each
week. The amount to be withheld to pay this execution may be less than 25%, but it
can never be more. The computations you complete below will allow you to calculate
the exact amount which should be withheld from this employee's wages.
Unless the court orders that this execution is to be for a smaller amount, you must
withhold and pay over the maximum amount which you figure out using the
computations below. Your employee has a right to request the court to reduce the
amount withheld, but until you receive notice that the court has agreed to allow the
amount to be reduced, you must withhold the maximum amount.
VI. Your duty to comply with this execution — You have a legal duty to make
deductions from your employee's wages and pay any amounts deducted as requifed
by this execution. If you do not, legal action may be taken against you. If you are
found to be in contempt of a court.order, you may be held liable to the Judgment
Creditor for the amounts of wages which you did not withhold from your employee.
Vil. Discipline against your employee — You may not discipline, suspend or
discharge your employee because this wage execution has been served upon you. If
you do untawfully take action against your employee, you may be liable to pay him all
of his lost eamings and employment benefits from the time of your action to the time
that the employeeis reinstated.
The law allows you to take disciplinary measures against the employee if you are
served with more than 7 wage executions against his/her wages in any calendar year.
Section |. Calculation Of Employee's Disposable Earnings
isposable Earnings" means that part of the earnings of an individual remaining after the deduction from those earnings of amounts to be
withheld for payment of federal income and employment taxes, normal retirement contributions, union dues and initiation fees, group life
insurance premiums, health insurance premiums, and federal tax levies.
1. Employee's gross compensation per week.
2. Federal income tax withheld .
3. Federal employment tax.......
4. Normal retirement contribution «. .
5. Union dues and initiation fees... ...c+eegheernsiet ren ye
6. Group life insurance premium ..
7. Health insurance premium. .nn-ieesierserte =
8. Other federal tax levies-.....
9. Total allowable deductions (Add lines 2-8) -,.-5 erevseri
10. Weekly Disposable Earnings (Subtract line 9 from line 1)
Section Il. Calculation Of Employee's Disposable Earnings
To be calculated by employer
‘Column 1 I Column 2
A-1. Weekly disposable earnings (from line 10 above)
4-2, 25% of disposable earnings for week
B-1. Weekly disposable earnings (from line 10 above)
‘S
Ss
B-2, Forly times the higher of the current federal minimum
~ hourly wage orstate full minimum fair wage.
Ss
Amount by which line 8-1 exceeds B-2 $
Amount of Execution (Employer must pay the lesser of the two. amounts in column 2 unless the court
erdered limitation set forth befow is a lesser amount, inwhich case the employer must pay that lesser amount)
Court orderedllimitation (if any, to be entered by clerk)
JD-CV-3 Rev. 2-15 Page 2 of 2EXEMPTION AND MODIFICATION
CLAIM FORM, WAGE EXECUTION StaTg of Connegricut
a 3a i lev 11-1 . U ( ul T
SSaesusca0e ne we jud.ctgav
Name and maiing address of judoment debtor (persen who mist Pay money) oF
attomey of Ldament debler
(Tobe completed by judgment credior (parse who money is bad fo}) MKMPEX
T Matthew Barks 7 Instructions
Ta: jatthew Bar To proper officer: Complele Section If below and
. make sevvice on employer in accordance with the
524 Providence Pike instructians on form JD-CV- 3.
Putnam CT 06260
To employer: Complete Section itl below and
17-14987 dnmesately deliver to emplayee,
u i
Section I - Judgment Creditor {person who money is paid to) must fill out this section and attach to one copy of the
wage execution application (JD-CV-3).
eee ee reat ON een oa oe natn
eel Sooo CORES | Superior Court 185 CHURCH ST PUTNAM CT 06260
Name of case 7 Matthew Barks Becket numbsr
MIDLAND FUNDING LLC v. WWM-CV-17-5007598-S
‘Name of judgment debtor (peraan who wusl pay money)
Matthew
~"[Oste of serwice of wage execution on employer
fa
Section i. Employer must fill out this section and IMMEDIATELY send one copy of this form and the Wage
Execution form {JD-CV-3} to the judgment debtor (General Statutes Section 52-36 fa(d}j.
Name and address of empisyer . Teleplione numbes of payroll department
“Bais of daivery cr ming to judgment dabior "| Totat amount of wage executions ———=S«| Amount to be takan eut ftom waakly earnings
$ $
Section IV - Notice to judgment debtor (person who must pay money)
Because a judgment entered against you, the attached execution has been issued against wages earned by you fram the employer
named above, Beginning twenty (20) days from the Date of Service of Wage Execution on Employer indicated above. the employer will
temove from your weekly eamings an amount of money which leaves you with (a) seventy-five percent (78%) of your dispesabie earnings
OR (b) forty (40) times the higher of the minimum hourly wage set by federal law or state law; whichever is the larger amount. On page 2 of
this form are the sections of the Connecticut General Statutes which your employer must foflow to figure out (calculate) the weekly amount
that may be taken out of your wages to agree with the wage execution. If you think that your employer has not calculated the weekly
amount coirectly, you shouid tell your employer.
Your earnings may be exempt from execution (do not have to be taken) —- Any wages eamed by a person who gets public
assistance under an incentive earnings or similar program are exempt from {may not be taken from you) execution. (Section 52-352b(d) of
the Connecticut Generat Statutes).
How to claim an exemption allowed by law — If you want te claim that your earnings are exempt by law from execution you must filt
out and sign the Claim of Exemption on page 2 of this form and return this exemption and modification clalm farm to the Supetior Court at
the above address.
Wien the clerk of the Superior Court gets thls form, the clerk will netity you and the judgment creditor of the date on which the court will
have a hearing to figure out the issues raised by your claim. If this form: is received by the court no later than twenty (20) days from the Date
of Service of Wage Execution on Employer indicated above, the employer will not begin withhalding (removing) your eamings from your
wages until af:er your claim is fgured out by the court A claim may also be filed after the twenty (20) day period, No earnings claimed to be
exempt may be withhe'd from any employee until the claim has been figured out,
Modification of execution — If you.have reasonable cause to befieve that you have a right to a modification (change) of the wage
execution and you want to ask for a modification (te have [ess money taken from your wages), you must fill out the Claim for Modification on
page 2 of this form and return this exemption and modification claim form to the Superior Court
at the address listed above. i For Court Use Only
When the clerk of Superior Caurt gets this form the clerk will tell you and the judgment lRedae ee
creditor the date on which the court will have a hearing to figure out the issues raised by your i
claim. If this form is received by the court no later than twenty (20) days from the Date of Service |
of Wage Execution on Employer indicated above, the employer will not begin withholding your i
earnings until after your claim is figured out by the court A claim may aiso be filed afzer the twenty
(20) day period, No eamings subject to a claim for modification may be withheld from any |
employee until the claim has been figured out,
Setting aside judgment — If the judgment was made against you because you did not
come to court, you may, within four (4) months of the date the court made its judgment and upon
belief that you have reasonable cause. ask the court to set aside the judgment entered against i
you and the case will begin again. A fee will be charged to you for a motion to set aside judgment. |
Page 1 af 2 Exemption and Todification claim17-14987
Section V - Claim of exemption established by law
|, the Judgment Debtor (person who must pay money), claim and certify under the penalty of false statement that my
earnings are exempt from execution (do not have to be taken) because:
C2 | get public assistance and earn wages under an incentive earnings or similar program and my earnings
are exempt from execution, or
OU Other statutory exemption (state exemption and statutory citation) _
Signed (Judgment Debtor) Name and address of judgment debtor Telephone number
Section VI - Claim for modification
|, the Judgment Debtor (person who must pay money), ask for a modification of the wage execution against me because:
New amount requested ‘Describe why you think you should get a modification (have less money taken from your wages)
/ Per week
Signed (Judgment Debtor) Date signed Name and complete mailing address of judgment debtor | Telephone number
1
Section Vil - Agreement to a modification
The Judgment Creditor(s) (person who money is paid to) agrees to the modification of the Wage Execution claimed
“Signed (Judgment Credtor(s) or Altorney)) ‘Name of Judgment Creditor(s) or Attomey Date
Section Vill - Notice of hearing on exemption / modification claim
Bate of hearing } Time ofhearing [Courtroom
i M. By the Assistant Clerk
Section IX - Order of court
It is ordered that:
‘Signed (Judge, Magistrate, Assistant Clerk) = Date signed
By order of the court
General Statutes
1. The following is the part of section 52-361a({) of the Connecticut General Statutes which says what part of your wages can be removed by the employer
and given tothe judament creditor.
“"The maximum part of the aggregate weekly earnings of an individual which may be subject under this section to levy or other withholding for payment of
‘a judgment is the lesser of (1) twenty-five (25) percent of his. disposable earnings for that week, or (2) the amount by which his disposable earnings for that
week exceed forty (40) times the higher of (A) the minimum hourly wage prescribed by section 6(a)(1) of the Fair Labor Standards Act of 1938, 25 U.S.C.
Section 206(a)(1), or (B) the full minimum fair wage established by subsection (i) of section 31-58, in effect at the time the earnings are payable."
2. The following is the part of section 52-350a(4) of the Connecticut General Statutes which defines disposable earnings and which defines what parts of
your wages which can not be included in your total earnings when figuring out (calculating) the weekly amount which is subject fo execution.
“Disposable eamings' means that part of the eamings of an individual remaining after the deduction from those eamings of amounts requiredto be
withheld for payment of federal income and employment taxes, normal retirement contributions, union dues and initiation fees, group life insurance
premiums, health insurance premiums and federal tax levies."
| The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a
reasonable accommodation in accordance with the ADA, contact the clerk at the court named on page 1 or an ADA
contact person listed at www.jud.ct.gov/ADA/.
JD-CV-3a (back/page 2) Rev. 11-15 Page 2 of 2
Preview
WAGE EXECUTION PROCEEDINGS: STATE OF CONNECTICUT APPLICATION, ORDER, EXECUTION SUPERIOR COURT JD-CV-3 Rev. 2-15 www.jud:ct.gov ca: 29 U.S.C. 206(a)(1) 1. 2. 3. 4, S. §§ 31-58()), 52-350a, 52-361a, 52-: ‘356d, SS aa Employer: See Page 2 for instructions Instructions Clerk 1. Issue execution by signing original, 2. Enter any court ordered limitation at the bottom of 2. section Il on page 2. Judgment Creditor or Attorney Unless filing electronically, prepare original and four copies. Attach form JD-CV-3a to this form, or include with execution as one PDF electronic form. Present original and 3 copies to clerk of court. 3. Return original and 2 copies if on paper. Keep one copy for your file. 4, Retain/scan copy for court file, Name and mailing address of Judgment Creditor or Attomey y APPWEX INC WAGEEX IRR Proper Officer ee - Leave one signed copy with employer. Make return on signed original. Leave one copy of Modification and Exemption Claim form (JD-CV-3a) with employer and fill in “Date of Service" on form. - (To be completed by Judgment Creditor or Attomey) 4 ADA NOTICE The Judicial Branch of the State MIDLAND FUNDING LLC ‘of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a C/O London & London reasonable accommadation in accordance 5 te with the ADA, contact a court clerk or an ADA 48 Christian Lane contact person listed at www.jud.ct.gow/ADA. Newington, CT 06111 1417-14987 a] ‘Address of court (Number, street, and town) GA. ID. Housing Session | Date of judgment | Docket number = (Fol) 155 CHURCH ST PUTNAM CT 06260 07-Nov-17 WWM-CV-17-5007598-S — Name(s) and address(es) of Judgment Creditor(s) Name(s) and address(es) of Judgment Debior(s) MIDLAND FUNDING LLC Matthew Barks C/O London & London 48 Christian Lane | 524 Providence Pike § Newington, CT 06111 Putnam CT 06260 [Name and address of employer of Judgment Debtor (known) 2447 ware Rd “Telephone number of employer (i knowny 3 += [Westview Commons Dayville CT 06241 860/428-2230 ‘& FT Amount of judgment (Include where applicable, prejudgment interest and alfomey’s fees) ‘2. Amount of costs and fees — + | 624.68 100.95 3. Total amount of judgment, costs and fees (Add 7 and 2) Total amount paid (any “I ‘5 400805. Russell L. London | 06/07/2022 860-666-4500 To: Any Proper Officer By the authority of the State of Connecticut, you are ordered to cause any wages due to the Judgment Debtor(s), not exceeding the Amount of Execution calculated on page 2, to be paid to the Judgment Creditor(s) until the judgment is satisfied, including postjudgment interest as ordered by the court, if applicable, plus t lication fee(s) and other Court ordered postjudgment costs and fees, and your own fees or until theexecutidn is modified or set aside. Serve this eyécution wihin one year of this, date poe return of service to this courtwithin thirty days Page 1 of 2 ‘WAGE EXECUTION PROCEEDINGSImportant Notice To Employer 17-14987 You are being served with a wage execution, a court order requiring you to withhold non-exempt wages from a person employéd by you. This execution is being served on you because your employee, the Judgment Debtor (on page 1), has had a judgment entered against him/her by the Superior Court requiring him/her to pay judgment, costs and fees to the Judgment Creditor (6n page 1) and has not made payment of the total amount of the judgment plus any costs and fees as shown on page 1. This notice is to inform you of the actions you must take in order to comply with the law regarding wage executions. Please read each section carefully. |. You must notify the employee — Your employee has certain legal rights which may allow him/her to request the court to change or stop this execution upon his/her wages. A notice of his/her rights and how to get a hearing in court is attached to the second copy of the wage execution given to you by the officer. You must complete your portion of the wage execution and your portion of the exemption and modification claim form arid deliver or mail, postage prepaid, a copy of these papers to your employee immediately so that your employee can make any claims allowed by law. 1, Execution not effective for 20 days — This execution is not effective until after 20 days from the day the officer served these papers.on you. No money should be deducted from your employee's wages until the first wages you pay to your employee after the 20-day period ends. If your employee elects within the 20-day period to make a claim to the court that his/her wages are partially or totally exempt from to pay this judgment or he/she seeks to have the amount of this execution changed, wages are not ta be withheld fram the employee until the court decides the claims or determines the rights of your employee in this.case. If you are not notified that your employee has filed papers with the court, the execution is to be enforced after 20 days from the date of service on you, IL Stay of execution — No earings clairied to be exempt or subject to a claim for modification may be withheld from any employee unt determination of the claim by the court. IV. Only one execution issued under section 52-36ta of the General Statutes is, to be satisfied at a time — You must make deductions from your employee's wages and pay over the withheld money against only one execution issued under General Statutes section $2-361a at a time. If you are served with more than one execution issued under General Statutes section §2-364a against this employee's wages, the executions are to be satisfied in the order in which you are. served with them. (Income withholdings and voluntary wage deductions for support of a family, # there are any, must be paid before this execution. Family support income withholdings and voluntary wage deductions are issued on Form JD-FIM-1,) V. Maximum amount deducted — The maximum amount which ean be legally withheld from your employee's wages is 25% of hishher disposable eamings for each week. The amount to be withheld to pay this execution may be less than 25%, but it can never be more. The computations you complete below will allow you to calculate the exact amount which should be withheld from this employee's wages. Unless the court orders that this execution is to be for a smaller amount, you must withhold and pay over the maximum amount which you figure out using the computations below. Your employee has a right to request the court to reduce the amount withheld, but until you receive notice that the court has agreed to allow the amount to be reduced, you must withhold the maximum amount. VI. Your duty to comply with this execution — You have a legal duty to make deductions from your employee's wages and pay any amounts deducted as requifed by this execution. If you do not, legal action may be taken against you. If you are found to be in contempt of a court.order, you may be held liable to the Judgment Creditor for the amounts of wages which you did not withhold from your employee. Vil. Discipline against your employee — You may not discipline, suspend or discharge your employee because this wage execution has been served upon you. If you do untawfully take action against your employee, you may be liable to pay him all of his lost eamings and employment benefits from the time of your action to the time that the employeeis reinstated. The law allows you to take disciplinary measures against the employee if you are served with more than 7 wage executions against his/her wages in any calendar year. Section |. Calculation Of Employee's Disposable Earnings isposable Earnings" means that part of the earnings of an individual remaining after the deduction from those earnings of amounts to be withheld for payment of federal income and employment taxes, normal retirement contributions, union dues and initiation fees, group life insurance premiums, health insurance premiums, and federal tax levies. 1. Employee's gross compensation per week. 2. Federal income tax withheld . 3. Federal employment tax....... 4. Normal retirement contribution «. . 5. Union dues and initiation fees... ...c+eegheernsiet ren ye 6. Group life insurance premium .. 7. Health insurance premium. .nn-ieesierserte = 8. Other federal tax levies-..... 9. Total allowable deductions (Add lines 2-8) -,.-5 erevseri 10. Weekly Disposable Earnings (Subtract line 9 from line 1) Section Il. Calculation Of Employee's Disposable Earnings To be calculated by employer ‘Column 1 I Column 2 A-1. Weekly disposable earnings (from line 10 above) 4-2, 25% of disposable earnings for week B-1. Weekly disposable earnings (from line 10 above) ‘S Ss B-2, Forly times the higher of the current federal minimum ~ hourly wage orstate full minimum fair wage. Ss Amount by which line 8-1 exceeds B-2 $ Amount of Execution (Employer must pay the lesser of the two. amounts in column 2 unless the court erdered limitation set forth befow is a lesser amount, inwhich case the employer must pay that lesser amount) Court orderedllimitation (if any, to be entered by clerk) JD-CV-3 Rev. 2-15 Page 2 of 2EXEMPTION AND MODIFICATION CLAIM FORM, WAGE EXECUTION StaTg of Connegricut a 3a i lev 11-1 . U ( ul T SSaesusca0e ne we jud.ctgav Name and maiing address of judoment debtor (persen who mist Pay money) oF attomey of Ldament debler (Tobe completed by judgment credior (parse who money is bad fo}) MKMPEX T Matthew Barks 7 Instructions Ta: jatthew Bar To proper officer: Complele Section If below and . make sevvice on employer in accordance with the 524 Providence Pike instructians on form JD-CV- 3. Putnam CT 06260 To employer: Complete Section itl below and 17-14987 dnmesately deliver to emplayee, u i Section I - Judgment Creditor {person who money is paid to) must fill out this section and attach to one copy of the wage execution application (JD-CV-3). eee ee reat ON een oa oe natn eel Sooo CORES | Superior Court 185 CHURCH ST PUTNAM CT 06260 Name of case 7 Matthew Barks Becket numbsr MIDLAND FUNDING LLC v. WWM-CV-17-5007598-S ‘Name of judgment debtor (peraan who wusl pay money) Matthew ~"[Oste of serwice of wage execution on employer fa Section i. Employer must fill out this section and IMMEDIATELY send one copy of this form and the Wage Execution form {JD-CV-3} to the judgment debtor (General Statutes Section 52-36 fa(d}j. Name and address of empisyer . Teleplione numbes of payroll department “Bais of daivery cr ming to judgment dabior "| Totat amount of wage executions ———=S«| Amount to be takan eut ftom waakly earnings $ $ Section IV - Notice to judgment debtor (person who must pay money) Because a judgment entered against you, the attached execution has been issued against wages earned by you fram the employer named above, Beginning twenty (20) days from the Date of Service of Wage Execution on Employer indicated above. the employer will temove from your weekly eamings an amount of money which leaves you with (a) seventy-five percent (78%) of your dispesabie earnings OR (b) forty (40) times the higher of the minimum hourly wage set by federal law or state law; whichever is the larger amount. On page 2 of this form are the sections of the Connecticut General Statutes which your employer must foflow to figure out (calculate) the weekly amount that may be taken out of your wages to agree with the wage execution. If you think that your employer has not calculated the weekly amount coirectly, you shouid tell your employer. Your earnings may be exempt from execution (do not have to be taken) —- Any wages eamed by a person who gets public assistance under an incentive earnings or similar program are exempt from {may not be taken from you) execution. (Section 52-352b(d) of the Connecticut Generat Statutes). How to claim an exemption allowed by law — If you want te claim that your earnings are exempt by law from execution you must filt out and sign the Claim of Exemption on page 2 of this form and return this exemption and modification clalm farm to the Supetior Court at the above address. Wien the clerk of the Superior Court gets thls form, the clerk will netity you and the judgment creditor of the date on which the court will have a hearing to figure out the issues raised by your claim. If this form: is received by the court no later than twenty (20) days from the Date of Service of Wage Execution on Employer indicated above, the employer will not begin withhalding (removing) your eamings from your wages until af:er your claim is fgured out by the court A claim may also be filed after the twenty (20) day period, No earnings claimed to be exempt may be withhe'd from any employee until the claim has been figured out, Modification of execution — If you.have reasonable cause to befieve that you have a right to a modification (change) of the wage execution and you want to ask for a modification (te have [ess money taken from your wages), you must fill out the Claim for Modification on page 2 of this form and return this exemption and modification claim form to the Superior Court at the address listed above. i For Court Use Only When the clerk of Superior Caurt gets this form the clerk will tell you and the judgment lRedae ee creditor the date on which the court will have a hearing to figure out the issues raised by your i claim. If this form is received by the court no later than twenty (20) days from the Date of Service | of Wage Execution on Employer indicated above, the employer will not begin withholding your i earnings until after your claim is figured out by the court A claim may aiso be filed afzer the twenty (20) day period, No eamings subject to a claim for modification may be withheld from any | employee until the claim has been figured out, Setting aside judgment — If the judgment was made against you because you did not come to court, you may, within four (4) months of the date the court made its judgment and upon belief that you have reasonable cause. ask the court to set aside the judgment entered against i you and the case will begin again. A fee will be charged to you for a motion to set aside judgment. | Page 1 af 2 Exemption and Todification claim17-14987 Section V - Claim of exemption established by law |, the Judgment Debtor (person who must pay money), claim and certify under the penalty of false statement that my earnings are exempt from execution (do not have to be taken) because: C2 | get public assistance and earn wages under an incentive earnings or similar program and my earnings are exempt from execution, or OU Other statutory exemption (state exemption and statutory citation) _ Signed (Judgment Debtor) Name and address of judgment debtor Telephone number Section VI - Claim for modification |, the Judgment Debtor (person who must pay money), ask for a modification of the wage execution against me because: New amount requested ‘Describe why you think you should get a modification (have less money taken from your wages) / Per week Signed (Judgment Debtor) Date signed Name and complete mailing address of judgment debtor | Telephone number 1 Section Vil - Agreement to a modification The Judgment Creditor(s) (person who money is paid to) agrees to the modification of the Wage Execution claimed “Signed (Judgment Credtor(s) or Altorney)) ‘Name of Judgment Creditor(s) or Attomey Date Section Vill - Notice of hearing on exemption / modification claim Bate of hearing } Time ofhearing [Courtroom i M. By the Assistant Clerk Section IX - Order of court It is ordered that: ‘Signed (Judge, Magistrate, Assistant Clerk) = Date signed By order of the court General Statutes 1. The following is the part of section 52-361a({) of the Connecticut General Statutes which says what part of your wages can be removed by the employer and given tothe judament creditor. “"The maximum part of the aggregate weekly earnings of an individual which may be subject under this section to levy or other withholding for payment of ‘a judgment is the lesser of (1) twenty-five (25) percent of his. disposable earnings for that week, or (2) the amount by which his disposable earnings for that week exceed forty (40) times the higher of (A) the minimum hourly wage prescribed by section 6(a)(1) of the Fair Labor Standards Act of 1938, 25 U.S.C. Section 206(a)(1), or (B) the full minimum fair wage established by subsection (i) of section 31-58, in effect at the time the earnings are payable." 2. The following is the part of section 52-350a(4) of the Connecticut General Statutes which defines disposable earnings and which defines what parts of your wages which can not be included in your total earnings when figuring out (calculating) the weekly amount which is subject fo execution. “Disposable eamings' means that part of the eamings of an individual remaining after the deduction from those eamings of amounts requiredto be withheld for payment of federal income and employment taxes, normal retirement contributions, union dues and initiation fees, group life insurance premiums, health insurance premiums and federal tax levies." | The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact the clerk at the court named on page 1 or an ADA contact person listed at www.jud.ct.gov/ADA/. JD-CV-3a (back/page 2) Rev. 11-15 Page 2 of 2