Preview
state Fe
a Past ib, £242
cetter ID 10005447190 ayiile: S297 4 bee bL698
Rev. 10/22
ts pion S
at Nhe
Nhe 4908 ~ can af
a8 O04agg908
Exemption and Modification Claim Forfn af O8
Employer Wage Execution in Accordance with Tax Warrant
feAny eo
jection I (Completed by Commissioner of Revenue Services) a % SbZ ou ‘ By
(cau Name ofemplo
Nashin t, Hartford CT 06106 ULBRICH STAINLESS STEELS & SPECIAL METAL
Name of debtor Warrant number and date. of issuance of warrant
MICHAEL L OUTLAW 76409, 09/29/2023
—— Section II (Completed by employer upon receipt of exemption claim form)
Complete Séction Iarid Send oné Copyof this form and the tax warrant tothe ‘debtor-in accordance with-Gonn.-Gen.-Stat-§52-361a(d). —
Address of employer ‘Address mailed to
\ Dudler Avenue
ep
Coe MA Ad, CT OUNF2
Date of mailing VE ‘otal amount of wage execution Amount fo be taken out from weekly earnings
\olel>3 & (oes 313.5%
Section Ill - Notice to Debtor
The attached tax warrant has been issued against wages earned by you from the employer named above, Beginning twenty (20) days from the Date of
Issuance of Warrant 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
Jarger amount. The statutes your employer must follow to calculate the weekly amount that may be taken out of your wages fo comply with the warrant
are listed below under General Statutes. 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 - Your éarhings may be protected from execution by statues or regulations of the State of
Connecticut or of the United States. A checklist and a description of the exemptions established by law are listed:on the last page.
How to Claim an Exemption Allowed by Law- If you believe that your earings are exempt by law from execution, you must fill out and sign Section
IV— Claim of Exemption Established by'Law, below and mail or deliver this Exemption And Modification Claim Form to the Superior Court at the
address of court indicated above, The court clerk will notify you, your employer, arid the Commissicner of Revenue Services of the date on which a
hearing will be held by the court to determine the issues raised by your claim. If this form is received by the Court no later than twenty (20) days from the
Date of Issuance of Warrant indicated above, the employer will not begin withholding your earnings until after your claim is reviewed 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
resolved.
How to Claim a 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 request a modification (to have less money taken from your wages), you must fill out Section V — Claim for Modification,
below and mail or deliver this Exemption And Modification Claim Form to the Superior Court at the address of court indicated above. The court clerk will
notify you, your employer, and the Commissioner of Revenue Services of the date on which a hearing will be held by the court to determine the issues
raised-by-your-claim..lf this form isreceived by the court no later than twenty (20) days from the Date of Issuance of Warrant indicated above, the
employer wil! not begin withholding your earnings until after your claim is reviewed by the court.
A claim may also be filed aiter thie
twenty
(20) day
period. No earnings claimed to be exempt may be withheld from any employee until the claim has been resolved.
. General Statutes. .... ..
The following is the part ‘of Conn. Gen. Stat. §52-361a(f) which identifies 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 earnings for that week, or (2) the amount by which his
disposable eamings 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 earnings are payable."
The following is the part of Conn. Gen. Stat. §52-350a(4) which defines disposable earnings and, in doing so.
explains what parts of your wages which cannot be included in your total earnings when figuring out (calculating) the
weekly amount which is subject to execution.
‘Disposable earnings means that part of the earnings of an individual remaining after the deduction from those earnings of amounts required to
be withheld for payment of federal income and employment taxes, normal retirement contributions, unio! Peep fees, group life
insurance premiums, health insurance premiums and federal tax levies.
OCT 23 2023
450 Columbus Blvd., Suite. 4 File Your Taxes Electronically HARTFORD 1D CT 06103-1837
rtal.ct.govIDRS
Affirmative Action / Equal Opportunity Employer 7
ft
Letter ID: 10005447180 bL698,
Rev, 10/22
section} IV) laim of Exemption Established by Law (Completed bi y debtor upon receipt of Exemption and Modification Claim Form.)
led above, claim and certi ify under the penalty of false statement that my earings are exempt from execution (do not
have to be tak en) because:
C1 1 get public assistance and earn wages under an incentive earnings or similar program and
my.earnings are exempt from
execution; .
OR
O Other statutory exemption (List each exemption below, the amount of the exemption, and the statutory authority
for the
exemption. Attach additional pages as needed.)
Statutory Authority Amount Claimed as Exempt [Described Claimed Exemptions Established by Law t:
Signed Date Address of debtor
Section V - Claimed for Modification (Completed by debtor upon receipt of Exemption and Modification Claim
Form)
|, the debtor, ask for modification of wage execution against me because:
Amount Requested Per Week Describe why you think you should have less money taken from your wages
Wecdshie Wouldn't beable to pay mij bills
FO .voRa weal
Ly Li
Date Address of debtor
/23 | 499 CHG Ly Wl uv
10/20 CT O67
Section VI - Notice to the Clerk of Superior Court (Completed by clerk upon receipt of the exemption claim form)
1
Complete Section V and send a file-stamped copy to:
1 The debtor at the address of debtor indicated in Section Norv;
2. The employer indicatedin Section II; :
3. The Department of Revenue Services, Office of Counsel, 11th Fi oor, 450 Columbus Blvd, Suite 1, Hartford, cr 06103; and
4. The Office of the Attorney General, Attention: Finance, Departmi ent 4, 55 Elm Street, Hartford CT 06106
Date of hearing Time of hearing Courtroom number
Order of the Court
Judge Date
450°Columbus Bivd., Suite: File Your Taxes Electronically Hartford, CT 06103-1837
portal.ct.gov/DRS
Affirmative A \ction / Equal Opportunity Employer 8
Preview
state Fe a Past ib, £242 cetter ID 10005447190 ayiile: S297 4 bee bL698 Rev. 10/22 ts pion S at Nhe Nhe 4908 ~ can af a8 O04agg908 Exemption and Modification Claim Forfn af O8 Employer Wage Execution in Accordance with Tax Warrant feAny eo jection I (Completed by Commissioner of Revenue Services) a % SbZ ou ‘ By (cau Name ofemplo Nashin t, Hartford CT 06106 ULBRICH STAINLESS STEELS & SPECIAL METAL Name of debtor Warrant number and date. of issuance of warrant MICHAEL L OUTLAW 76409, 09/29/2023 —— Section II (Completed by employer upon receipt of exemption claim form) Complete Séction Iarid Send oné Copyof this form and the tax warrant tothe ‘debtor-in accordance with-Gonn.-Gen.-Stat-§52-361a(d). — Address of employer ‘Address mailed to \ Dudler Avenue ep Coe MA Ad, CT OUNF2 Date of mailing VE ‘otal amount of wage execution Amount fo be taken out from weekly earnings \olel>3 & (oes 313.5% Section Ill - Notice to Debtor The attached tax warrant has been issued against wages earned by you from the employer named above, Beginning twenty (20) days from the Date of Issuance of Warrant 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 Jarger amount. The statutes your employer must follow to calculate the weekly amount that may be taken out of your wages fo comply with the warrant are listed below under General Statutes. 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 - Your éarhings may be protected from execution by statues or regulations of the State of Connecticut or of the United States. A checklist and a description of the exemptions established by law are listed:on the last page. How to Claim an Exemption Allowed by Law- If you believe that your earings are exempt by law from execution, you must fill out and sign Section IV— Claim of Exemption Established by'Law, below and mail or deliver this Exemption And Modification Claim Form to the Superior Court at the address of court indicated above, The court clerk will notify you, your employer, arid the Commissicner of Revenue Services of the date on which a hearing will be held by the court to determine the issues raised by your claim. If this form is received by the Court no later than twenty (20) days from the Date of Issuance of Warrant indicated above, the employer will not begin withholding your earnings until after your claim is reviewed 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 resolved. How to Claim a 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 request a modification (to have less money taken from your wages), you must fill out Section V — Claim for Modification, below and mail or deliver this Exemption And Modification Claim Form to the Superior Court at the address of court indicated above. The court clerk will notify you, your employer, and the Commissioner of Revenue Services of the date on which a hearing will be held by the court to determine the issues raised-by-your-claim..lf this form isreceived by the court no later than twenty (20) days from the Date of Issuance of Warrant indicated above, the employer wil! not begin withholding your earnings until after your claim is reviewed by the court. A claim may also be filed aiter thie twenty (20) day period. No earnings claimed to be exempt may be withheld from any employee until the claim has been resolved. . General Statutes. .... .. The following is the part ‘of Conn. Gen. Stat. §52-361a(f) which identifies 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 earnings for that week, or (2) the amount by which his disposable eamings 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 earnings are payable." The following is the part of Conn. Gen. Stat. §52-350a(4) which defines disposable earnings and, in doing so. explains what parts of your wages which cannot be included in your total earnings when figuring out (calculating) the weekly amount which is subject to execution. ‘Disposable earnings means that part of the earnings of an individual remaining after the deduction from those earnings of amounts required to be withheld for payment of federal income and employment taxes, normal retirement contributions, unio! Peep fees, group life insurance premiums, health insurance premiums and federal tax levies. OCT 23 2023 450 Columbus Blvd., Suite. 4 File Your Taxes Electronically HARTFORD 1D CT 06103-1837 rtal.ct.govIDRS Affirmative Action / Equal Opportunity Employer 7 ft Letter ID: 10005447180 bL698, Rev, 10/22 section} IV) laim of Exemption Established by Law (Completed bi y debtor upon receipt of Exemption and Modification Claim Form.) led above, claim and certi ify under the penalty of false statement that my earings are exempt from execution (do not have to be tak en) because: C1 1 get public assistance and earn wages under an incentive earnings or similar program and my.earnings are exempt from execution; . OR O Other statutory exemption (List each exemption below, the amount of the exemption, and the statutory authority for the exemption. Attach additional pages as needed.) Statutory Authority Amount Claimed as Exempt [Described Claimed Exemptions Established by Law t: Signed Date Address of debtor Section V - Claimed for Modification (Completed by debtor upon receipt of Exemption and Modification Claim Form) |, the debtor, ask for modification of wage execution against me because: Amount Requested Per Week Describe why you think you should have less money taken from your wages Wecdshie Wouldn't beable to pay mij bills FO .voRa weal Ly Li Date Address of debtor /23 | 499 CHG Ly Wl uv 10/20 CT O67 Section VI - Notice to the Clerk of Superior Court (Completed by clerk upon receipt of the exemption claim form) 1 Complete Section V and send a file-stamped copy to: 1 The debtor at the address of debtor indicated in Section Norv; 2. The employer indicatedin Section II; : 3. The Department of Revenue Services, Office of Counsel, 11th Fi oor, 450 Columbus Blvd, Suite 1, Hartford, cr 06103; and 4. The Office of the Attorney General, Attention: Finance, Departmi ent 4, 55 Elm Street, Hartford CT 06106 Date of hearing Time of hearing Courtroom number Order of the Court Judge Date 450°Columbus Bivd., Suite: File Your Taxes Electronically Hartford, CT 06103-1837 portal.ct.gov/DRS Affirmative A \ction / Equal Opportunity Employer 8