Free NOTICE AND CLAIM FORM, SUPPORT INCOME WITHHOLDING - Connecticut

NOTICE AND CLAIM FORM SUPPORT INCOME WITHHOLDING
JD-FM-68 Rev. 10-99 C.G.S. § 46b-231, 52-362 P.A. 99-193 § 5, 6

INSTRUCTIONS TO PREPARER

1.Use in connection with a contingent income withholding order or if there is a delinquency in an amount greater than or equal to 30 days obligation or if a withholding order was requested to enforce a prior order of support regardless of any delinquency and whether or not such order is subject to a contingent income withholding. 2.Complete original and 2 copies. 3.Serve original on obligor. 4.Retain 2 copies for file.
INSTRUCTIONS TO CLERK

Upon receipt of this claim enter appearance of obligor pursuant to C.G.S. Sec. 52-362(d) and set matter for hearing. Send file-stamped copy of claim to person or state agency to whom the support order is payable and notify all parties of the hearing date.
Name and mailing address of obligor

TO:

CONNECTICUT SUPERIOR COURT
www.jud.ct.gov
DOCKET NO. NAME OF CASE DELINQUENCY YES NO AMT. OF DELINQUENCY (if applicable) DURATION OF DELINQUENCY (if applicable) DAYS WEEKS DATE OF SUPPORT ORDER DATE THIS NOTICE MAILED BALANCE OWED (if applicable)

IV-D CASE

NON IV-D CASE

AS OF (Date)

NAME AND ADDRESS OF COURT NAME AND ADDRESS OF PERSON OR STATE AGENCY TO WHOM SUPPORT ORDER IS PAYABLE

DELINQUENCY - If indicated above, you are delinquent in your payments due under a support order in the amount shown above, which amount is greater than or equal to 30 days obligation and any additional amounts accruing until the effective date of the withholding order. WITHHOLDING ORDER - A withholding order against your income, which income may include Unemployment Compensation, has become effective. You have fifteen (15) days from receipt of this notice to request a hearing before the court or family support magistrate division. The withholding order applies to any current or subsequent employer or period of employment. The withholding order secures payment of past and future amounts due under the support order and may secure an additional amount computed in accordance with the child support guidelines established under C.G.S. Sec. 46b-215a, to be applied toward liquidation of any arrearage accrued under the support order. REQUESTING A COURT HEARING - You may request a hearing before the court or family support magistrate by completing the claim form on page 2 of this notice and returning it to the court or family support magistrate division at the above address or by submitting a written notice of your request for a hearing to the court or family support magistrate. This must be done within 15 days after your receipt of this notice. At such hearing, you may contest the claimed delinquency, if any, and/or the imposition of the income withholding, seek modification of the withholding order, and claim any other applicable state or federal exemption with respect to your income. EXEMPTIONS - If your income is subject to a withholding order, a portion of your income will not be withheld. Only
SIGNED (Dependent or attorney)

disposable income is subject to a withholding order. Disposable income means that part of the income of an individual remaining after deduction from that income of amounts required to be withheld for the payment of federal, state and local income taxes, employment taxes, normal retirement contributions, union dues and initiation fees and group life and health insurance premiums. The amount withheld may not exceed the maximum amount permitted under section 1673 of title 15 of the United States Code: If you are supporting a spouse or dependent child other than the spouse or child with respect to whose support the order is issued, the maximum amount of your disposable income that may be withheld is 50% of such income unless you are twelve weeks or more in arrears, in which case the maximum is 55% of such income. If you are not supporting a spouse or dependent child other than the spouse or child with respect to whose support the order is issued, the maximum amount of your disposable income that may be withheld is 60% of such income unless you are twelve weeks or more in arrears, in which case the maximum is 65%. In no event however, under state law may you be left with less than 85% of the first $145 of disposable income. Such exemptions will automatically take effect, they need not be claimed. The computation of the amount withheld will be done by the payer of the income involved based on information supplied by the party in whose favor the withholding order issued. If you believe that an incorrect amount of your income is being withheld due to incorrect information being supplied to the payer of the income and you would like the amount withheld modified, you must request a court hearing. MODIFICATION OF SUPPORT ORDER - You have a right to seek a modification of, or raise a defense to, the support order. You may do so by filing a separate, proper motion with the court or family support magistrate division. You must pay a fee when the motion is filed. Such fee may be waived by the court in certain situations.
DATE SIGNED

PRINT NAME OF PERSON SIGNING

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CLAIM FORM
INSTRUCTIONS TO OBLIGOR 1. If you wish to request a hearing to contest the claimed delinquency, if any, and/or the imposition of the income withholding, seek modification of the WITHHOLDING ORDER, or claim any lawful exemption with respect to your earnings, complete Part I below and return this claim form to the clerk of the court or family support magistrate division, at the address indicated on page 1, within fifteen days of your receipt of this notice. A hearing will be scheduled and you will be notified when to appear in court. If you wish to seek modification of the SUPPORT ORDER, see Part II below.

2.

PART l

DEFENSES AND EXEMPTIONS

I hereby request a hearing to: ("X" all that apply) seek modification of the WITHHOLDING ORDER (You may not use this form to seek a modification of the SUPPORT ORDER. See Part II below.) contest the claimed delinquency and/or the imposition of the income withholding because the amount of the delinquency is incorrect. (Explain below) I am not behind 30 days or more in my support obligation. (Explain below) claim the following exemption other (state defense or exemption) (Explain below. See "Exemptions" on page 1) (Explain below)

BRIEFLY EXPLAIN, IN THIS SPACE, THE BASIS OF THE DEFENSE OR EXEMPTION WHICH YOU ARE CLAIMING.

NAME AND SIGNATURE
NAME AND ADDRESS OF PERSON MAKING CLAIM (Print or type) SIGNED (Person making claim) TELEPHONE NO. DATE SIGNED

PLEASE ENTER THE APPEARANCE OF:
NAME OF ATTORNEY, LAW FIRM, OR OBLIGOR, IF PRO SE ADDRESS OF ATTORNEY, LAW FIRM, OR PRO SE PARTY JURIS NO. (If attorney or law firm) TELEPHONE NO.

PART ll NOTICE OF RIGHT TO SEEK MODIFICATION OF SUPPORT ORDER You have a right to seek a modification of, or raise a defense to, the support order. You may do so by filing a separate, proper motion with the court or family support magistrate division. Such motion must comply with all applicable statutes and court rules. You must pay a fee when the motion is filed. Such fee may be waived by the court or family support magistrate division in certain situations. You may not use this form to seek a modification of the SUPPORT ORDER. PART III
IT IS HEREBY ORDERED THAT:

ORDER OF COURT

SIGNED (Judge, Family Support Magistrate, Assistant Clerk)

DATE SIGNED

JD-FM-68 (Page 2 of 2) Rev. 10-99

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