Free Wage Execution and Modification Claim Form  - Connecticut


File Size: 139.6 kB
Pages: 3
Date: June 10, 2004
File Format: PDF
State: Connecticut
Category: Bankruptcy
Author: Dietz
Word Count: 1,030 Words, 6,254 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ctb.uscourts.gov/Forms/Wageexecutionmod.pdf

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UNITED STATES BANKRUPTCY COURT DISTRICT OF CONNECTICUT AT : : : : Docket No. : : : WAGE EXECUTION EXEMPTION AND MODIFICATION CLAIM FORM

(The employer must complete Section III below and mail this "Wage Execution Exemption and Modification Claim Form", the "Wage Execution Notice to Employer", and the "Wage Execution" to the employee). SECTION I (to be completed by prevailing party and attached to wage execution) ADDRESS OF COURT: UNITED STATES BANKRUPTCY COURT OFFICE OF THE CLERK

NAME OF JUDGMENT DEBTOR: NAME AND ADDRESS OF PREVAILING PARTY'S ATTORNEY:

TELEPHONE NUMBER: SECTION II (to be completed by Marshal or Sheriff) DATE OF SERVICE OF WAGE EXECUTION: SECTION III (to be completed by employer) NAME AND ADDRESS OF EMPLOYER: TELEPHONE NUMBER OF PAYROLL DEPT.: DATE OF DELIVERY OR MALING TO JUDGMENT DEBTOR: TOTAL AMOUNT OF WAGE EXECUTION: AMOUNT TO BE TAKE OUT FROM WEEKLY EARNINGS:

SECTION IV

NOTICE TO EMPLOYEE

As a result of a judgment entered against you, the attached execution has been issued against wages earned by you from the employer named above. In compliance with this execution, the employer will remove from your weekly earnings an amount of money which leaves you with the greater of forty times the federal hourly minimum wage or seventyfive percent of your disposable earnings. (The federal minimum hourly wage in effect as of October 1, 19 $ per hour. Forty times the federal minimum wage as of October 1, 19 is $ ). is

Stated below are those sections of the "General Statutes" which your employer must follow in determining the weekly amount that may be taken out of your wages to satisfy the wage execution. If you determine that your employer has not calculated the weekly amount correctly, you should bring this to your employer's attention. YOUR EARNINGS MAY BE EXEMPT FROM EXECUTION - Any wages earned by a public assistance recipient under an incentive earnings or similar program, are exempt from execution (Conn. Gen. Stat. 52-352(d)). HOW TO CLAIM EXEMPTION ALLOWED BY LAW - If you wish to claim that your earnings are exempt by law from execution, you must fill out and sign Section V below entitled "Claim of Execution" and return this entire Exemption and Modification Claim to the Bankruptcy Court at the above address. This form must be received by the Bankruptcy Court no later than 20 days from the Date of Service of Execution indicated above. Upon receipt of this form, the Clerk of the Bankruptcy Court will notify you and (insert name of party making application) of the date on which a hearing will be held by the court to determine the issues raised by your claim. MODIFICATION OF EXECUTION - If you have reasonable cause to believe that you are entitled to a modification of the wage execution and wish to have the execution so modified, you must fill out Section VI below, entitled the "Claim for Modification" and return this entire Exemption and Modification Claim Form to the Bankruptcy Court at the above address. A claim for modification may be made at any time. If you believe that you are entitled to a modification of the wage execution, complete and return this form to the Bankruptcy Court no later than 20 days from the date of service of execution indicated above. No earnings subject to the claim for modification may be withheld from you until the court renders a decision on your claim. If you complete and return this form seeking a modification of the wage execution later than 20 days after the date of service of execution indicated above, your earnings will continue to be withheld until the court renders a decision on your claim. Upon receipt of this form, the Clerk of the Bankruptcy Court will notify you and the party making the application of the date on which a hearing will be held by the court to determine the issues raised by your claim. SETTING ASIDE JUDGMENT - If judgment entered against you because of your failure to appear or respond in court, you may be able to acquire relief from the judgment pursuant to the provisions of Rule 60(b) of the Federal Rules of Civil Procedure.

SECTION V

CLAIM OF EXEMPTION ESTABLISHED BY LAW herein claim

I, the Judgement Debtor, (insert name)

and certify under the penalty of false statement that my earnings are exempt from execution because: (Check one) I am a public assistance recipient earning wages under an incentive or similar program and my earnings are exempt from execution, or Other statutory exemption (cite state exemption and statutory citation) Signature Print Name: Address (PRINT) SECTION VI CLAIM FOR MODIFICATION Telephone Number

I, the Judgment Debtor, (insert name) herein move for a modification of the wage execution against me as follows: New amount requested (per week): Describe basis for modification:

Signature Print Name: Address (PRINT)

Telephone Number

Print Form

GENERAL STATUES

1. The following is the part of Section 52-361a(f) of the Connecticut General Statutes which denotes what portion of your wages is subject to execution. 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 percent of his/her disposable earnings for that week; or (2) the amount by which his/her disposable earnings for that week exceed forty times the federal minimum hourly wage prescribed by Section (A)(1) of the Federal Labor Standards Act of 19/38, U.S.C. Title 29, Section 206(a)(1), in effect at the time the earnings are payable. 2. The following is that part of Section 52-350a(4) of the Connecticut General Statutes which defines disposable earnings, and which defines portions of your wage which must be excluded from your total earnings when 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, federal tax levies and state income tax deductions authorized pursuant to C.G.S. Section 12-34b.