Preview
APPWEX
WAGE EXECUTION PROCEEDINGS STATE OF CONNECTICUT
APPLICATION, ORDER, EXECUTION SUPERIOR COURT
JD-CV-3 Rev. 2-15 www.jud.ct.gov
CGS. §§ 31-58(), 52-350a, 52-361a, 52-3564, WAGEEX
29 U.S.C. 206(a)(1) Employer. See Page 2 for instructions
Instructions INNA
Judgment Creditor or Attorney Clerk Proper Officer
1, Unless filing electronically, prepare original and four copies. 1. Issue execution by signing original. 1. Leave one signed copy with employer.
2. Attach form JD-CV-3a to this form, or include with execution 2. Enter any court ordered limitation at the bottom of 2. Make return on signed original.
as one PDF electronic form. section Il on page 2. 3. Leave one copy of Modification and Exemption
3. Present original and 3 copies to clerk of court. 3. Return original and 2 copies if on paper. Claim form (JD-CV-3a) with employer and fill in
4. Keep one copy for your file. 4, Retain/scan copy for court file. “Date of Service” on form.
Name and mailing address of Judgment Creditor or Attomey
(To be completed by Judgment Creditor or Aitomey) 4 "ADA NOTICE
cv 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 accommodation in accordance
age with the ADA, contact a court clerk or an ADA
48 Christian Lane contact person listed al wwwjud.ct.govV/ADA
Newington, CT 06111 48-18706
L J
‘Address of court (Number, street, and town) []oa. [X]vD. — L_]Housing Session | Date of judgment | Docket number
(Faia) 1061 MAIN STREET BRIDGEPORT CT 06604 06/13/2019 FBT-CV-19-6085471-S
“~~ Name(s) and address(es) of Judgment Creditor(s) Name(s) and address(es) of Judgment Debtor(s)
MIDLAND FUNDING LLC. CURTIS BRICKHOUSE
C/O London & London
48 Christian Lane 896 LINDLEY ST #3
§ Newington, CT 06111 BRIDGEPORT CT 06606
'% [Name and address of employer of Judgment Debior (if known) 9902 N Wesishore Blvd ‘Telephone number of employer (f known)
2 OSI Restaurant Services Tampa FL 33607 813/282-1225
& |7T. Amount of judgment (include where applicable, prejudgment interest and altomney’s fees) 2. Amount of costs and fees.
Tt 1934.43 101.95
3. Tolal amount of judgment, costs and fees (Add 7 and 2) . Tolal amount unpaid (Subtract 4 from 3)
1,036.38 . 1,036.38
& Application fee for wage execution (If not waived by the court) | 7. Application fees paid for prior executions on this judgment =|
105.00 0.00 Check if applicable
B. Other Court ordered postjudgment cosis and fees * | 9. Totaloflines 5, 6, 7 and = Postjudgment interest was
0.00 1,141.38 ordered by the Court
The above-named Judgment Creditor(s) recovered a judgment against the above-named Judgment Debtor(s). The Judgment Debtor(s) has/have
failed to pay the total amount due on that judgment
Pursuant to the Connecticut General Statutes, the Court listed above entered an order that the judgment be paid by the above-named
Judgment Debtor(s) in the following installment payments
The amount of __ 39-00 was ordered to be paid in_Weekly (weekly, monthly, or other) installment payments. See Note below
(Note: This is not the amount the employer must pay. Employer must pay the amount of execution calculated on page 2 of this form
The court ordered that installment payments begin on _ 97/05/2019 (commencement date)
The Judgment Debtor(s) failed to comply with the Installment Payment Order
Therefore, the Judgment Creditor{s) applies/apply for this execution upon the wages of the Judgment Debtor(s) for the remaii
due on the judgment shown in line 9 above
‘Signed (Judgment Creditor or Atlomey) ‘On (Date) Telephone Number
> 400805 Russell L. London | 08/06/2019 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 postiudgment interest as ordered by the court, if
applicable, plus the application fee(s) and other Court ordered postjudgment costs and fees, and your own
fees or until the execution is modified or set aside
Serve this execution within one year of this date, and make return of service to this courtwithin thirty days
from satisfaction of the executjpn
ing amount
For Court Use Only
File date
Execution
On (Daley
Luge
Page 1 of 2 WAGE EXECUTION PROCEEDINGS
lowImportant Notice To Employer
You are being served with a wage execution, a court order requiring you to withhold non-
18-18706
xempt wages from a person employed 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 (on 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.
1. You must notify the employee — Your employee has certain legal rights which
may allow hinvher to request the court to change or stop this execution upon his/her
wages. Anotice of hisMher 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 and deliver or mai, postage prepaid, a copy of these papers fo your
employee immediately so that your employee can make any claims allowed by law.
ll, 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 hisher wages are pattially or totally exempt from
execution to pay this judgment or he/she seeks to have the amount ofthis execution
changed, wages are not to be withheld from 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 fled 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 claimed to be exempt or subject to a claim for
modification may be withheld from any employee until determination of the claim by
the court.
IV. Only one execution issued under section 52-361a 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 52-361 at a time. If you are served with more than one execution
issued under General Statutes section 52-361a 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 wthhokdings and voluntary
wage deductions are issued on Form JO-FM-1,)
V. Maximum amount deducted — The maximum amount which can be legally
withheld from your employee's wages is 25% of his/her 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 required
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 unlawiully take action against your employee, you may be liable to pay him all
of his lost earnings and employment benefits from the time of yaur action to the time
that the employee is 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 I. Calculation Of Employee's Disposable Earnings
“Disposable 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 ..
§. Union dues and initiation fees
6. Group life insurance premium
7. Health insurance premium, ........6.6.er eee
8. Other federai tax levies...
9. Total allowable deductions (Add lines 2-8) ...
40. Weekly Disposable Earnings (Subtract line 9 from line 1)
Section II. Calculation Of Employee's Disposable Earnings
To be calculated by employer
Column 1
A-1. Weekly disposable earnings (from fine 10 above)
A-2. 25% of disposable earnings for week
8-1. Weekly disposable earnings (from line 10 above)
Forty times the higher of the current federal minimum
B2 hourly wage or state full minimum fair wage.
Amount by which line B-1 exceeds B-2
Amount of Execution (Employer must pay the lesser of the two amounts in column 2 unless the court
‘ordered limitation set forth below is a lesser amount, in which case the employer must pay that lesser amount)
‘Court ordered limitation (if any, to be entered by clerk)
JO-CV-3 Rev. 2-15
Page 2 of 2EXEMPTION AND MODIFICATION
CLAIM FORM, WAGE EXECUTION STATE OF CONNECTICUT &
pe
JD-CV-3a Rey. 11-15
C.G.S. § 31-58), 52-212, $2-350a, (52-362b, 52-3614, SUPERIOR COURT
52-3610, 28 U.S.C. 208(aK1) www jud.ct
Name and mailing address of judgment debtor (person who must pay money} or a I
attomey of pidgment debtor MEMPEX
{To be completed by judgment creditor (person who money is paid to}
™% BRICKHOUSE Instructions
To: CURTIS To proper officer: Complete Section i below and
Oo: make service on employer in accordance with the
896 LINDLEY ST #3 instructions on form JD-CV-3,
BRIDGEPORT CT 06606 To employer: Complete Section If! betow and
18-18706 immediately deliver to employee
L !
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).
- Geographical Name and address of court
Kl beret Seat O18... Superior Court 1061 MAIN STREET BRIDGEPORT CT 06604
“Nate of eaee CURTIS BRICKHOUSE Daekeracinber
MIDLAND FUNDING LLC v. FBT-CV-19-6085471-S
Name of judgment debtor (person whe must pay money)
CURTIS BRICKHOUSE
Section ll - Proper Officer must complete this section
Warne of proper officer Dale of service of wage execution on employer
Section It - 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 52-361a(d)).
Name and address of employer Telephone number of payroll department
Date of delivery or mailing to judgment debtor Total amount of wage execution ‘Amount to be taken cut fom weekly eammgs
$ $
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 from the employer
named above. Beginning twenty (20) days from the Date of Service of Wage Execution on Employer indicated above, the employer will
remove from your weekly earnings an amount of money which leaves you with (a) seventy-five percent (75%) of your disposable 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 follow 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 correctly, you should 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 General Statutes).
How to claim an exemption allowed by law — if you want to claim that your earnings are exempt by law from execution you must fill
out and sign the Claim of Exemption on page 2 of this form and return this exemption and modification claim form to the Superior Court at
the above address.
When the clerk of the Superior Court gets this form, the clerk will notify 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 withholding (removing) your eamings from your
wages until after your claim is figured out by the court. A claim may also be filed after the twenty (20) day period. No earnings claimed to be
exempt may be withheld from any employee until the claim has been figured out.
Modification of execution — If you have reasonable cause to believe that you have a right to a modification (change) of the wage
execution and you want to ask for a modification (to have less 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. For Court Use Only ]
When the clerk of Superior Court gets this form the clerk will tell you and the judgment File date
creditor 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 withholding your
earnings until after your claim is figured out by the court. A claim may alse be filed after the twenty
(20) day period. No earnings 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
you and the case will begin again. A fee will be charged to you for a motion to set aside judgment.
Page 1 of2 Exemption and modification claim18-18706
Section V - Claim of exemption established by law
1, 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
| get public assistance and earn wages under an incentive earnings or similar program and my earnings
are exempt from execution, or
Other statutory exemption (state exemption and statutory citation)
‘Signed (Judgment Debtor) [Date signed [Name and address of judgment debtor T 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 Namie and complete mailing address of judgment debtor | Telephone number
|
!
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 Creditor(s) or Attorney) ‘Name of Judgment Creditor(s) or Attomey Date
Section Vill - Notice of hearing on exemption / modification claim
Date of hearing | Time of hearing Courtroom
—_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 foliowing is the part of section 52-36 1a(f) of the Connecticut General Statutes which says what part of your wages can be removed by the employer
and given to the judgment 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 earings for that week, or (2) the amount by which his disposable earings 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, 29 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 earings 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 to execution.
“Disposable earings’ means that part of the earings of an individual remaining after the deduction from those earings 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
APPWEX WAGE EXECUTION PROCEEDINGS STATE OF CONNECTICUT APPLICATION, ORDER, EXECUTION SUPERIOR COURT JD-CV-3 Rev. 2-15 www.jud.ct.gov CGS. §§ 31-58(), 52-350a, 52-361a, 52-3564, WAGEEX 29 U.S.C. 206(a)(1) Employer. See Page 2 for instructions Instructions INNA Judgment Creditor or Attorney Clerk Proper Officer 1, Unless filing electronically, prepare original and four copies. 1. Issue execution by signing original. 1. Leave one signed copy with employer. 2. Attach form JD-CV-3a to this form, or include with execution 2. Enter any court ordered limitation at the bottom of 2. Make return on signed original. as one PDF electronic form. section Il on page 2. 3. Leave one copy of Modification and Exemption 3. Present original and 3 copies to clerk of court. 3. Return original and 2 copies if on paper. Claim form (JD-CV-3a) with employer and fill in 4. Keep one copy for your file. 4, Retain/scan copy for court file. “Date of Service” on form. Name and mailing address of Judgment Creditor or Attomey (To be completed by Judgment Creditor or Aitomey) 4 "ADA NOTICE cv 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 accommodation in accordance age with the ADA, contact a court clerk or an ADA 48 Christian Lane contact person listed al wwwjud.ct.govV/ADA Newington, CT 06111 48-18706 L J ‘Address of court (Number, street, and town) []oa. [X]vD. — L_]Housing Session | Date of judgment | Docket number (Faia) 1061 MAIN STREET BRIDGEPORT CT 06604 06/13/2019 FBT-CV-19-6085471-S “~~ Name(s) and address(es) of Judgment Creditor(s) Name(s) and address(es) of Judgment Debtor(s) MIDLAND FUNDING LLC. CURTIS BRICKHOUSE C/O London & London 48 Christian Lane 896 LINDLEY ST #3 § Newington, CT 06111 BRIDGEPORT CT 06606 '% [Name and address of employer of Judgment Debior (if known) 9902 N Wesishore Blvd ‘Telephone number of employer (f known) 2 OSI Restaurant Services Tampa FL 33607 813/282-1225 & |7T. Amount of judgment (include where applicable, prejudgment interest and altomney’s fees) 2. Amount of costs and fees. Tt 1934.43 101.95 3. Tolal amount of judgment, costs and fees (Add 7 and 2) . Tolal amount unpaid (Subtract 4 from 3) 1,036.38 . 1,036.38 & Application fee for wage execution (If not waived by the court) | 7. Application fees paid for prior executions on this judgment =| 105.00 0.00 Check if applicable B. Other Court ordered postjudgment cosis and fees * | 9. Totaloflines 5, 6, 7 and = Postjudgment interest was 0.00 1,141.38 ordered by the Court The above-named Judgment Creditor(s) recovered a judgment against the above-named Judgment Debtor(s). The Judgment Debtor(s) has/have failed to pay the total amount due on that judgment Pursuant to the Connecticut General Statutes, the Court listed above entered an order that the judgment be paid by the above-named Judgment Debtor(s) in the following installment payments The amount of __ 39-00 was ordered to be paid in_Weekly (weekly, monthly, or other) installment payments. See Note below (Note: This is not the amount the employer must pay. Employer must pay the amount of execution calculated on page 2 of this form The court ordered that installment payments begin on _ 97/05/2019 (commencement date) The Judgment Debtor(s) failed to comply with the Installment Payment Order Therefore, the Judgment Creditor{s) applies/apply for this execution upon the wages of the Judgment Debtor(s) for the remaii due on the judgment shown in line 9 above ‘Signed (Judgment Creditor or Atlomey) ‘On (Date) Telephone Number > 400805 Russell L. London | 08/06/2019 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 postiudgment interest as ordered by the court, if applicable, plus the application fee(s) and other Court ordered postjudgment costs and fees, and your own fees or until the execution is modified or set aside Serve this execution within one year of this date, and make return of service to this courtwithin thirty days from satisfaction of the executjpn ing amount For Court Use Only File date Execution On (Daley Luge Page 1 of 2 WAGE EXECUTION PROCEEDINGS lowImportant Notice To Employer You are being served with a wage execution, a court order requiring you to withhold non- 18-18706 xempt wages from a person employed 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 (on 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. 1. You must notify the employee — Your employee has certain legal rights which may allow hinvher to request the court to change or stop this execution upon his/her wages. Anotice of hisMher 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 and deliver or mai, postage prepaid, a copy of these papers fo your employee immediately so that your employee can make any claims allowed by law. ll, 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 hisher wages are pattially or totally exempt from execution to pay this judgment or he/she seeks to have the amount ofthis execution changed, wages are not to be withheld from 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 fled 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 claimed to be exempt or subject to a claim for modification may be withheld from any employee until determination of the claim by the court. IV. Only one execution issued under section 52-361a 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 52-361 at a time. If you are served with more than one execution issued under General Statutes section 52-361a 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 wthhokdings and voluntary wage deductions are issued on Form JO-FM-1,) V. Maximum amount deducted — The maximum amount which can be legally withheld from your employee's wages is 25% of his/her 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 required 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 unlawiully take action against your employee, you may be liable to pay him all of his lost earnings and employment benefits from the time of yaur action to the time that the employee is 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 I. Calculation Of Employee's Disposable Earnings “Disposable 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 .. §. Union dues and initiation fees 6. Group life insurance premium 7. Health insurance premium, ........6.6.er eee 8. Other federai tax levies... 9. Total allowable deductions (Add lines 2-8) ... 40. Weekly Disposable Earnings (Subtract line 9 from line 1) Section II. Calculation Of Employee's Disposable Earnings To be calculated by employer Column 1 A-1. Weekly disposable earnings (from fine 10 above) A-2. 25% of disposable earnings for week 8-1. Weekly disposable earnings (from line 10 above) Forty times the higher of the current federal minimum B2 hourly wage or state full minimum fair wage. Amount by which line B-1 exceeds B-2 Amount of Execution (Employer must pay the lesser of the two amounts in column 2 unless the court ‘ordered limitation set forth below is a lesser amount, in which case the employer must pay that lesser amount) ‘Court ordered limitation (if any, to be entered by clerk) JO-CV-3 Rev. 2-15 Page 2 of 2EXEMPTION AND MODIFICATION CLAIM FORM, WAGE EXECUTION STATE OF CONNECTICUT & pe JD-CV-3a Rey. 11-15 C.G.S. § 31-58), 52-212, $2-350a, (52-362b, 52-3614, SUPERIOR COURT 52-3610, 28 U.S.C. 208(aK1) www jud.ct Name and mailing address of judgment debtor (person who must pay money} or a I attomey of pidgment debtor MEMPEX {To be completed by judgment creditor (person who money is paid to} ™% BRICKHOUSE Instructions To: CURTIS To proper officer: Complete Section i below and Oo: make service on employer in accordance with the 896 LINDLEY ST #3 instructions on form JD-CV-3, BRIDGEPORT CT 06606 To employer: Complete Section If! betow and 18-18706 immediately deliver to employee L ! 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). - Geographical Name and address of court Kl beret Seat O18... Superior Court 1061 MAIN STREET BRIDGEPORT CT 06604 “Nate of eaee CURTIS BRICKHOUSE Daekeracinber MIDLAND FUNDING LLC v. FBT-CV-19-6085471-S Name of judgment debtor (person whe must pay money) CURTIS BRICKHOUSE Section ll - Proper Officer must complete this section Warne of proper officer Dale of service of wage execution on employer Section It - 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 52-361a(d)). Name and address of employer Telephone number of payroll department Date of delivery or mailing to judgment debtor Total amount of wage execution ‘Amount to be taken cut fom weekly eammgs $ $ 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 from the employer named above. Beginning twenty (20) days from the Date of Service of Wage Execution on Employer indicated above, the employer will remove from your weekly earnings an amount of money which leaves you with (a) seventy-five percent (75%) of your disposable 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 follow 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 correctly, you should 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 General Statutes). How to claim an exemption allowed by law — if you want to claim that your earnings are exempt by law from execution you must fill out and sign the Claim of Exemption on page 2 of this form and return this exemption and modification claim form to the Superior Court at the above address. When the clerk of the Superior Court gets this form, the clerk will notify 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 withholding (removing) your eamings from your wages until after your claim is figured out by the court. A claim may also be filed after the twenty (20) day period. No earnings claimed to be exempt may be withheld from any employee until the claim has been figured out. Modification of execution — If you have reasonable cause to believe that you have a right to a modification (change) of the wage execution and you want to ask for a modification (to have less 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. For Court Use Only ] When the clerk of Superior Court gets this form the clerk will tell you and the judgment File date creditor 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 withholding your earnings until after your claim is figured out by the court. A claim may alse be filed after the twenty (20) day period. No earnings 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 you and the case will begin again. A fee will be charged to you for a motion to set aside judgment. Page 1 of2 Exemption and modification claim18-18706 Section V - Claim of exemption established by law 1, 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 | get public assistance and earn wages under an incentive earnings or similar program and my earnings are exempt from execution, or Other statutory exemption (state exemption and statutory citation) ‘Signed (Judgment Debtor) [Date signed [Name and address of judgment debtor T 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 Namie and complete mailing address of judgment debtor | Telephone number | ! 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 Creditor(s) or Attorney) ‘Name of Judgment Creditor(s) or Attomey Date Section Vill - Notice of hearing on exemption / modification claim Date of hearing | Time of hearing Courtroom —_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 foliowing is the part of section 52-36 1a(f) of the Connecticut General Statutes which says what part of your wages can be removed by the employer and given to the judgment 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 earings for that week, or (2) the amount by which his disposable earings 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, 29 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 earings 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 to execution. “Disposable earings’ means that part of the earings of an individual remaining after the deduction from those earings 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