Fill and Sign the Claim Form Wage Execution

Exemption and modification claim Page 1 of 2 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)). Section III - 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) Instructions 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).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. 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. 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) ) Section II - Proper Officer must complete this section To: Judicial District Housing Session Total amount of wage execution $ Amount to be taken out from weekly earnings $ For Court Use Only File date Section IV - Notice to judgment debtor (person who must pay money) STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Geographical Area number Section I - Name and address of court Name of case Docket number Name of judgment debtor (person who must pay money) Name of proper officer Date of service of wage execution on employer Name and address of employer Telephone number of payroll department Date of delivery or mailing to judgment debtor *MXMPEX* M X M P E X Reset Form Print Form Page 2 of 2 JD-CV-3a (back/page 2) Rev. 11-15 Section VII - Agreement to a modification 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: New amount requested Signed (Judgment Debtor) Date signed 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) Name and address of judgment debtor Telephone number I, the Judgment Debtor (person who must pay money), ask for a modification of the wage execution against me because: Describe why you think you should get a modification (have less money taken from your wages) Signed (Judgment Debtor) Date signed Name and complete mailing address of judgment debtor Telephone number 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)) Date Date of hearing By the Assistant Clerk It is ordered that: Signed (Judge, Magistrate, Assistant Clerk) Date signed By order of the court 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." / Per week Section VI - Claim for modification Section VIII - Notice of hearing on exemption / modification claim Section IX - Order of court General Statutes Time of hearing Courtroom __. M. 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/. Name of Judgment Creditor(s) or Attorney Reset Form Print Form