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Wage Execution Claim Form

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EXEMPTION AND MODIFICATION CLAIM FORM, WAGE EXECUTION

JD-CV-3a Rev. 11-15

C.G.S. § 31-58(i), 52-212, 52-350a, 52-352b, 52-361a, 52-361b, 29 U.S.C. 206(a)(1)

Name and mailing address of judgment debtor (person who must pay money) or attorney of judgment debtor

(To be completed by judgment creditor (person who money is paid to))

To:

STATE OF CONNECTICUT

SUPERIOR COURT

www.jud.ct.gov

MXMPEX

Instructions

To proper officer:

Complete Section II below and make service on employer in accordance with the instructions on form JD-CV-3.

To employer:

Complete Section III below and immediately deliver to employee.

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).

Name of judgment debtor (person who must pay money)

Section II - Proper Officer must complete this section

Name of proper officer

Date of service of wage execution on employer

Section III - 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

Date of delivery or mailing to judgment debtor

Telephone number of payroll department

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.

When the clerk of Superior Court gets this form the clerk will tell you and the judgment 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.

For Court Use Only

File date

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:

I 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

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

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 Creditor(s) or Attorney))

Name of Judgment Creditor(s) or Attorney

Date

Section VIII - Notice of hearing on exemption / modification claim

Date of hearing

Time of hearing

Courtroom

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 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/.

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What the Wage Execution Claim Form Is

The Wage Execution Claim Form is a legal document used to collect a judgment by directing an employer or payer to withhold and remit a portion of an employee’s wages. It typically follows a court judgment or administrative order and includes claimant and debtor details, judgment specifics, and the required withholding amount or formula. Courts or judgment creditors use this form to initiate wage garnishment or execution proceedings, and employers rely on it to determine payroll deductions consistent with federal and state wage-garnishment rules.

Why the Form Matters for Collecting Judgments

A properly completed Wage Execution Claim Form creates a clear legal instruction to employers and reduces delays in collecting unpaid judgments. It documents the creditor’s claim, provides notice to the debtor and employer, and helps ensure payroll withholdings comply with statutory limits and priority rules.

Why the Form Matters for Collecting Judgments

Who Typically Prepares and Uses This Form

Each party has a defined role: creditors initiate the claim, courts authorize execution, and employers carry out payroll deductions within legal limits.

  • Judgment creditors and in-house counsel who need to collect unpaid court awards.
  • Collection attorneys and process servers who prepare and serve the form.
  • Employers and payroll administrators who implement ordered withholdings.

Core Elements You Should Include

A professional Wage Execution Claim Form groups identification, judgment details, withholding instructions, service information, employer notice, and signature blocks for enforceability.

Claimant

Name and contact information for the party seeking execution; full mailing address and attorney contact if applicable.

Debtor

Full legal name, last known address, employer name and address, and any identifying numbers to avoid mismatches.

Judgment Details

Court name, docket or case number, judgment date, judgment amount, interest rate and outstanding balance as of a specific date.

Withholding Order

Clear formula or dollar amount to garnish, frequency (per pay period), and priority among other liens or garnishments.

Service Info

Method and date of service on the employer and debtor plus proof of service or certificate when required.

Signatures

Signature of authorized claimant or attorney with date, and space for employer acknowledgment and completion tracking.

Step-by-Step: How to Complete the Wage Execution Claim Form

Follow these sequential steps to prepare the form, serve parties, and initiate employer withholding.

  • 01
    Prepare Form: Populate claimant, debtor, judgment, and employer fields.
  • 02
    Attach Judgment: Include certified judgment or court order copy.
  • 03
    Serve Employer: Deliver form per court or state service rules.
  • 04
    Record Proof: File proof of service and retain copies.

Typical Enforcement Workflow at a Glance

This sequence summarizes how a completed form moves from creditor to employer and into payroll withholding.

  • File Judgment: Obtain a final court judgment or administrative order.
  • Prepare Claim: Complete the Wage Execution Claim Form accurately.
  • Serve Employer: Serve the employer and debtor per local rules.
  • Execute Withholding: Employer withholds amounts and remits to claimant or court.

Setting Up an Online Wage Execution Workflow

When using eForms and eSubmission, configure fields, authentication, and routing before sending to employers or courts.

Field Configuration
Mandatory Fields Claimant, debtor, employer, judgment amount, date
Authentication Email verification or SMS code for signers
Attachments Require certified judgment PDF upload
Routing Send to employer then file proof of service

Technical Requirements for eSubmission and eSigning

Ensure the chosen platform supports ESIGN/UETA-compliant signatures, secure transport (TLS), and retention capabilities required for court admissibility and employer compliance.

  • Document Formats: PDF and DOCX supported
  • Authentication: Email or SMS OTP
  • Audit Trail: IP, timestamp, action log

Typical Timelines and When Actions Must Happen

Timelines vary by jurisdiction; use these common milestones to set expectations and confirm local requirements.

Post-Judgment Preparation:

Prepare and serve the form promptly after a final judgment is entered.

Service on Employer:

Serve employer according to state rules — immediate proof required in many jurisdictions.

Payroll Action:

Employer typically begins withholding on the next payroll cycle after proper notice.

Reporting:

Creditors should file proof of service and any employer acknowledgments with the court.

Modification Requests:

Debtor or employer may request modification or exemption per statutory procedures.

Common Mistakes That Delay Enforcement

  • Using incomplete employer contact information that prevents proper service and delays withholding.
  • Mismatching debtor names or DOBs, producing disputes and refusal to process by payroll.
  • Failing to attach a certified judgment or providing an unsigned copy instead of a court-certified document.
  • Neglecting to account for protected income or statutory exemptions that limit garnishment amounts.

Risks and Potential Consequences of Errors

Dismissal Risk: Improper service may lead to dismissal of execution efforts
Employer Liability: Incorrect withholding can expose employers to legal claims
Contempt: Failure to comply with court orders risks contempt findings
Debtor Exemptions: Ignoring exemptions may result in returned funds or penalties
Administrative Fines: State penalties for improper collection procedures
Delay Costs: Errors increase collection time and reduce recovery value

eSignature Vendor Comparison for Completing and Serving Forms

Selecting an eSignature provider affects cost, compliance, and distribution. The table compares starting price, trial availability, bulk send, audit trail, and HIPAA support.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Security and Compliance Considerations for Electronic Execution

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
HIPAA: Supports HIPAA compliance; BAA required for PHI workflows
ESIGN / UETA: Meets ESIGN and UETA legal frameworks for e-signatures
Audit Trail: Complete timestamped logs with signer attribution
Certifications: SOC 2 Type II and ISO 27001 attestations available
Access Controls: Role-based permissions and SSO/SAML support

Frequently Asked Questions About the Wage Execution Claim Form

Answers to common questions about completing, serving, signing, and enforcing wage execution follow. Consult local court rules for jurisdictional specifics.


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