Preview
APPWEX
WAGE EXECUTION PROCEEDINGS STATE OF CONNECTICUT
APPLICATION, ORDER, EXECUTION
JD-CV-3 Rev. 2-15
SUPERIOR COURT
www.jud.ct.gov
1 1 1 11 1 111 11 11 1 11111 1
C.G.S. §§ 31-580), 52-350a, 52-361a, 52-356d, WAGE EX
29 U.S.C. 206(a)(1) Employer: See Page 2 for instructions
Instructions 1 1 1 1111111 111 1 11111 1
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 11 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 Attorney
ADA NOTICE
(To be completed by Judgment Creditor or Attorney)
---, The Judicial Branch of the State
CAPITAL ONE BANK (USA), N.A. of Connecticut complies with the Americans
with Disabilities Act (ADA). If you need a
C/0 London & London reasonable accommodation in accordance
with the ADA, contact a court clerk or an ADA
48 Christian Lane contact person listed at www.jud.ct.gov/ADA.
Newington, CT 06111 17-60584
L _J
Address of court
(Number, street, and town) D G.A. IX] J.D. D Housing Session Date of judgment
I 11/03/2017
Docket number
I WWM-CV-17-5007318-S
155 CHURCH ST PUTNAM CT 06260
Name(s) and address(es) of Judgment Creditor(s) Name(s) and address(es) of Judgment Debtor(s)
old)
CAPITAL ONE BANK (USA), N.A. SHANNON SAURO
C/0 London & London
48 Christian Lane 150 SPICER RD
.�
C: Newington, CT 06111 THOMPSON CT 06277-2323
I
0
:;:::;
ca (If known) Ill
Name and address of employer of Judgment Debtor 300 Wilmot Rd #3111 ATTN GARN DEPT Telephone number of employer
(if known)
Walgreens Deerfield, IL 60015 847/527-5370
1. Amount of judgment 2. Amount of costs and fees
C.
C. (Include where applicable, prejudgment interest and attorney's fees)
< Russell L. London 03/04/2020
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 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 execution.
Signed (Assistant Clerk of said court)
� I On (Date)
Page 1 of 2 WAGE EXECUTION PROCEEDINGS
17-60584
Important Notice To Employer
You are being served with a wage execution, a court order requiring you to withhold non-exempt 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.
I. Youmust notify the employee -
Your employee has certain legal rights which
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, if there are any,
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
must be paid before this executio n. Family support income withholdings and voluntary
second copy of the wage deductions are issued on Form JD-FM-1.)
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
V. Maximum amount deducted - The maximum amount which can belegally
claim form anddeliver or mail,
postage prepaid,
a copy ofthese papers to your
withheld from your employee's wages is 25% of his/her disposable earnings for each
employee immediately so that your employee can make any claims allowed by law.
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
II. Execution not effective for 20 days -
• This execution is not effective until after
the exact amount which should be withheld from this employee's wages.
20 days from the day the officer served these papers on you. No money should be
Unless the court orders that this execution is to be for a smaller amount, you must
deducted from your employee's wages until the first wages you pay to your employee
withholdand
after the 20-day period ends. If your employee elects within the 20-day period to pay overthe maximum amount which you figure
out using the
computations below. Your employee has a right to request the court to reduce the
make a claim to the court that his/her wages are partially or totally exempt from
amount withheld,
execution to pay this judgment or he/she seeks to have the amount of this execution but until you receive notice that the court has agreed to allow the
amount to be reduced, you must withhold the maximum amount.
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
VI. Yourduty to comply with this execution - You have a legal duty to make
that your employee has filed papers with the court, the execution is to be enforced
deductions from your employee's wages and pay any amounts deducted as required
after 20 days from the date of service on you. 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
Ill. Stay of execution - No earnings claimed to be exempt or subject to a claim for
Creditor for the amounts of wages which you did not withhold from your employee.
modification may be withheld from any employee until determination of the claim by
VII.Discipline
againstyour employee - You may notdiscipline,
suspend or
the court.
discharge your employee because this wage execution has been served upon you. If
you do unlawfully take action against your employee, you may be liable to pay
him all
IV. Only one execution issued under section 52-361a of the General Statutes is
of his lost earnings and employment benefits from the time of your action to the time
to be satisfied at a time - You must make deductions from your employee's wages
that the employee is reinstated.
and pay over the withheld money against only one execution issued under General
The law allows you to take disciplinary measures against the employee if you are
Statutes section 52-361 a at a time. If you are served with more than one execution
served with more than 7 wage executions against his/her wages in any calendar year.
issued under General Statutes section 52-361 a against this employee's wages, the
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
5. Union dues and initiation fees
6. Group life insurance premium ......................................................
7. Health insurance premium .
8. Other federal tax levies.
9. Total allowable deductions (Add lines 2-8)
10. 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 line 10 above)
A-2. 25% of disposable earnings for week
B-1. Weekly disposable earnings
(from line 10 above)
8_2_ Forty times the higher of the cur rent federal minimum
houri y wa ge or s tate full minimum fair wag e.
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)
JD-CV-3 Rev. 2-15
Page 2 of 2
EXEMPTION AND MODIFICATION
CLAIM FORM, WAGE EXECUTION STATE OF CONNECTICUT
JD-CV-3a Rev. 11-15
C.G.S. § 31-58(i), 52-212, 52-350a, 52-352b, 52-361 a,
SUPERIOR COURT
52-361 b, 29 U.S.C. 206(a)(1) www.jud.ct.gov
Name and mailing address of judgment debtor (person who must pay money) or 1111111111111111111111111111111111111111
attorney of judgment debtor MXMPEX
(To be completed by judgment creditor (person who money is paid to))
Instructions
1 SHANNON SAURO 1
To proper officer: Complete Section II below and
To: make service on employer in accordance with the
C/0
150 London
SPICER RD & London instructions on form JD-CV-3.
48 Christian
THOMPSON Lane
CT 06277-2323
To employer: Complete Section Ill below and
Newington, CT 06111 17-60584 immediately deliver to employee.
L ~
Section 1 _ 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
lvl Judicial Housing
~X District D Session D Area
number
Superior Court 155 CHURCH ST PUTNAM CT 06260
Name of case Docket number
SHANNON SAURO
CAPITAL ONE BANK (USA), N.A. v. WWM-CV-17-5007318-S
Name of judgment debtor (person who must pay money)
SHANNON SAURO
Section II - Proper Officer must complete this section
Name of proper officer Date of service of wage execution on employer
Section 111 _ 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 52-361 a(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 out from weekly 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 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 earned 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 earnings 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 also 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 claim
17-60584
Section V - Claim of exemption established by law
I, 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:
D I get public assistance and earn wages under an incentive earnings or similar program and my earnings
are exempt from execution, or
D other statutory exemption (state exemption and statutory citation) � � � ����������������� �
Signed (Judgment Debtor) Date signed Name and address of judgment debtor Telephone number
Section VI - Claim for modification
I, 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)
I Per week
Signed (Judgment Debtor) Date signed Name and complete mailing address of judgment debtor Telephone number
Section VII -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 Credifor(s) or Attorney)) Name of Judgment Creditor(s) or Attorney Date
Section VIII - Notice of hearing on exemption I modification claim
Date of h earing Time of hearing Courtroom
By the Assistant Clerk
_.M.
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(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 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, 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."
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 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, 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 (backlpage2)
Rev.11-15 Page 2 of 2
Preview
APPWEX WAGE EXECUTION PROCEEDINGS STATE OF CONNECTICUT APPLICATION, ORDER, EXECUTION JD-CV-3 Rev. 2-15 SUPERIOR COURT www.jud.ct.gov 1 1 1 11 1 111 11 11 1 11111 1 C.G.S. §§ 31-580), 52-350a, 52-361a, 52-356d, WAGE EX 29 U.S.C. 206(a)(1) Employer: See Page 2 for instructions Instructions 1 1 1 1111111 111 1 11111 1 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 11 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 Attorney ADA NOTICE (To be completed by Judgment Creditor or Attorney) ---, The Judicial Branch of the State CAPITAL ONE BANK (USA), N.A. of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a C/0 London & London reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA 48 Christian Lane contact person listed at www.jud.ct.gov/ADA. Newington, CT 06111 17-60584 L _J Address of court (Number, street, and town) D G.A. IX] J.D. D Housing Session Date of judgment I 11/03/2017 Docket number I WWM-CV-17-5007318-S 155 CHURCH ST PUTNAM CT 06260 Name(s) and address(es) of Judgment Creditor(s) Name(s) and address(es) of Judgment Debtor(s) old) CAPITAL ONE BANK (USA), N.A. SHANNON SAURO C/0 London & London 48 Christian Lane 150 SPICER RD .� C: Newington, CT 06111 THOMPSON CT 06277-2323 I 0 :;:::; ca (If known) Ill Name and address of employer of Judgment Debtor 300 Wilmot Rd #3111 ATTN GARN DEPT Telephone number of employer (if known) Walgreens Deerfield, IL 60015 847/527-5370 1. Amount of judgment 2. Amount of costs and fees C. C. (Include where applicable, prejudgment interest and attorney's fees) < Russell L. London 03/04/2020 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 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 execution. Signed (Assistant Clerk of said court) � I On (Date) Page 1 of 2 WAGE EXECUTION PROCEEDINGS 17-60584 Important Notice To Employer You are being served with a wage execution, a court order requiring you to withhold non-exempt 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. I. Youmust notify the employee - Your employee has certain legal rights which 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, if there are any, 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 must be paid before this executio n. Family support income withholdings and voluntary second copy of the wage deductions are issued on Form JD-FM-1.) 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 V. Maximum amount deducted - The maximum amount which can belegally claim form anddeliver or mail, postage prepaid, a copy ofthese papers to your withheld from your employee's wages is 25% of his/her disposable earnings for each employee immediately so that your employee can make any claims allowed by law. 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 II. Execution not effective for 20 days - • This execution is not effective until after the exact amount which should be withheld from this employee's wages. 20 days from the day the officer served these papers on you. No money should be Unless the court orders that this execution is to be for a smaller amount, you must deducted from your employee's wages until the first wages you pay to your employee withholdand after the 20-day period ends. If your employee elects within the 20-day period to pay overthe maximum amount which you figure out using the computations below. Your employee has a right to request the court to reduce the make a claim to the court that his/her wages are partially or totally exempt from amount withheld, execution to pay this judgment or he/she seeks to have the amount of this execution but until you receive notice that the court has agreed to allow the amount to be reduced, you must withhold the maximum amount. 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 VI. Yourduty to comply with this execution - You have a legal duty to make that your employee has filed papers with the court, the execution is to be enforced deductions from your employee's wages and pay any amounts deducted as required after 20 days from the date of service on you. 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 Ill. Stay of execution - No earnings claimed to be exempt or subject to a claim for Creditor for the amounts of wages which you did not withhold from your employee. modification may be withheld from any employee until determination of the claim by VII.Discipline againstyour employee - You may notdiscipline, suspend or the court. discharge your employee because this wage execution has been served upon you. If you do unlawfully take action against your employee, you may be liable to pay him all IV. Only one execution issued under section 52-361a of the General Statutes is of his lost earnings and employment benefits from the time of your action to the time to be satisfied at a time - You must make deductions from your employee's wages that the employee is reinstated. and pay over the withheld money against only one execution issued under General The law allows you to take disciplinary measures against the employee if you are Statutes section 52-361 a at a time. If you are served with more than one execution served with more than 7 wage executions against his/her wages in any calendar year. issued under General Statutes section 52-361 a against this employee's wages, the 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 5. Union dues and initiation fees 6. Group life insurance premium ...................................................... 7. Health insurance premium . 8. Other federal tax levies. 9. Total allowable deductions (Add lines 2-8) 10. 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 line 10 above) A-2. 25% of disposable earnings for week B-1. Weekly disposable earnings (from line 10 above) 8_2_ Forty times the higher of the cur rent federal minimum houri y wa ge or s tate full minimum fair wag e. 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) JD-CV-3 Rev. 2-15 Page 2 of 2 EXEMPTION AND MODIFICATION CLAIM FORM, WAGE EXECUTION STATE OF CONNECTICUT JD-CV-3a Rev. 11-15 C.G.S. § 31-58(i), 52-212, 52-350a, 52-352b, 52-361 a, SUPERIOR COURT 52-361 b, 29 U.S.C. 206(a)(1) www.jud.ct.gov Name and mailing address of judgment debtor (person who must pay money) or 1111111111111111111111111111111111111111 attorney of judgment debtor MXMPEX (To be completed by judgment creditor (person who money is paid to)) Instructions 1 SHANNON SAURO 1 To proper officer: Complete Section II below and To: make service on employer in accordance with the C/0 150 London SPICER RD & London instructions on form JD-CV-3. 48 Christian THOMPSON Lane CT 06277-2323 To employer: Complete Section Ill below and Newington, CT 06111 17-60584 immediately deliver to employee. L ~ Section 1 _ 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 lvl Judicial Housing ~X District D Session D Area number Superior Court 155 CHURCH ST PUTNAM CT 06260 Name of case Docket number SHANNON SAURO CAPITAL ONE BANK (USA), N.A. v. WWM-CV-17-5007318-S Name of judgment debtor (person who must pay money) SHANNON SAURO Section II - Proper Officer must complete this section Name of proper officer Date of service of wage execution on employer Section 111 _ 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 52-361 a(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 out from weekly 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 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 earned 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 earnings 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 also 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 claim 17-60584 Section V - Claim of exemption established by law I, 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: D I get public assistance and earn wages under an incentive earnings or similar program and my earnings are exempt from execution, or D other statutory exemption (state exemption and statutory citation) � � � ����������������� � Signed (Judgment Debtor) Date signed Name and address of judgment debtor Telephone number Section VI - Claim for modification I, 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) I Per week Signed (Judgment Debtor) Date signed Name and complete mailing address of judgment debtor Telephone number Section VII -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 Credifor(s) or Attorney)) Name of Judgment Creditor(s) or Attorney Date Section VIII - Notice of hearing on exemption I modification claim Date of h earing Time of hearing Courtroom By the Assistant Clerk _.M. 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(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 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, 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." 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 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, 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 (backlpage2) Rev.11-15 Page 2 of 2