Fill and Sign the Minnesota Levy Form

STATE OF MINNESOTA DISTRICT COURT COUNTY OF             JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Marriage of: Court File No.             , Judgment Creditor,       , NOTICE OF THIRD PARTY Judgment Debtor, LEVY AND DISCLOSURE       , Third Party, PLEASE TAKE NOTICE that pursuant to Minnesota Statutes, sections 551.04 and 551.06, the undersigned, as attorney for the judgment creditor, hereby makes demand and levies execution upon all earnings due and owing by you (up to $       ) to the judgment debtor for the amount of the judgment specified below. A copy of the writ of execution issued by the Court is enclosed. The unpaid judgment balance is       . This levy attaches all unpaid nonexempt disposable earnings owing or to be owed by you and earned or to be earned by the judgment debtor before and within the pay period in which the writ of execution is served and within all subsequent pay periods whose paydays occur within the 70 days after the service of this levy. In responding to this levy, you are to complete the attached disclosure form and worksheet and mail it to the undersigned attorney for the judgment creditor, together with your check payable to the above-named judgment creditor, for the non-exempt amount owed by you to the judgment debtor or for which you are obligated to the judgment debtor, within the time limits set forth in the aforementioned statutes. Dated: Name:       - 1 - Title:       Address:       Address:       City, State, Zip:       Phone:       Fax:       E-Mail:       Attorney Reg. No.:       - 2 - DISCLOSURE DEFINITIONS "EARNINGS": For the purpose of execution, "earnings" means compensation paid or payable to an employee for personal services or compensation paid or payable to the producer for the sale of agricultural products; milk or milk products; or fruit or other horticultural products produced when the producer is operating a family farm, a family farm corporation, or an authorized farm corporation, as defined in section 500.24, subdivision 2, whether denominated as wages, salary, commission, bonus, or otherwise, and includes periodic payments pursuant to a pension or retirement. "DISPOSABLE EARNINGS": Means that part of the earnings of a individual remaining after the deduction from those earnings of amounts required by law to be withheld. (Amounts required by law to be withheld do not include items such as health insurance, charitable contributions, or other voluntary wage deductions.) "PAYDAY": For the purpose of execution, "payday(s)" means the date(s) upon which the employer pays earnings to the judgment debtor in the ordinary course of business. If the judgment debtor has no regular payday, payday(s) means the 15th and the last day of each month. THE THIRD PARTY/EMPLOYER MUST ANSWER THE FOLLOWING QUESTIONS: 1. Do you now owe, or within 70 days from the date of the execution levy was served on you, will you or may you owe money to the judgment debtor for earnings? Yes No 2. Does the judgment debtor earn more than $       per week? (This amount is the federal minimum wage per week.) Yes No INSTRUCTIONS FOR COMPLETING THE EARNINGS DISCLOSURE A. If your answer to either question 1 or 2 is "No," then you must sign the affirmation on page 2 and return this disclosure to the judgment creditor's attorney within 20 days after it was served on you, and you do not need to answer the remaining questions: B. If your answers to both questions 1 and 2 are "Yes," you must complete this form and the Earnings Disclosure Worksheet as follows: For each payday that falls within 70 days from the date the execution levy was served on you, YOU MUST calculate the amount of earnings to be retained by completing steps 3 through 22 on page 2, and enter the amounts on the Earnings Disclosure Worksheet. UPON REQUEST, THE EMPLOYER MUST PROVIDE THE DEBTOR WITH INFORMATION AS TO HOW THE CALCULATIONS REQUIRED BY THIS DISCLOSURE WERE MADE. Each payday, you must retain the amount of earnings listed in column I on the Earnings - 3 - Disclosure Worksheet. You must pay the attached earnings and return this Earning Disclosure Form and the Earnings Disclosure Worksheet to the judgment creditor's attorney and deliver a copy to the judgment debtor within ten days after the last payday that falls within the 70-day period. If the judgment is wholly satisfied or if the judgment debtor's employment ends before the expiration of the 70-day period, your disclosure and remittance should be made within ten days after the last payday for which earnings were attached. For steps 3 through 11, "columns" refers to columns on the Earnings Disclosure Worksheet. 3. COLUMN A. Enter the date of judgment debtor's payday. 4. COLUMN B. Enter judgment debtor's gross earnings for each payday. 5. COLUMN C. Enter judgment debtor's disposable earnings for each payday. 6. COLUMN D. Enter 25 percent of disposable earnings (Multiply Column C by .25.) 7. COLUMN E. Enter here 40 times the hourly federal minimum wage ($____) times the number of work weeks included in each payday. (Note: If a pay period includes days in excess of whole work weeks, the additional days should be counted as a fraction of a work week equal to the number of work days in excess of a whole work week divided by the number of work days in a normal work week.) 8. COLUMN F. Subtract the amount in Column E from the amount in Column C, and enter here. 9. COLUMN G. Enter here the lesser of the amount in Column D and the amount in Column F. 10. COLUMN H. Enter here any amount claimed by you as a setoff, defense, lien, or claim, or any amount claimed by any other person as an exemption or adverse interest which would reduce the amount of earnings owing to the judgment debtor. (Note: Any indebtedness to you incurred within ten days prior to your receipt of the first execution levy on a debt may not be set off against the earnings otherwise subject to this levy. Any wage assignment made by the judgment debtor within ten days prior to your receipt of the first execution levy on a debt is void.) You must also describe your claim(s) and the claims of others, if known, in the space provided below the worksheet and state the name(s) and address(es) of these persons. Enter zero in Column H is there are no claims by you or others which would reduce the amount of earnings owning to the judgment debtor. 11. COLUMN I. Subtract the amount in Column H from the amount in Column G and enter here. This is the amount of earnings that you must retain for the payday for which the calculations were made. The total of all amounts entered in Column I is the amount to be remitted to the attorney for the judgment creditor. - 4 - AFFIRMATION I, Name (person signing Affirmation), am the third party/employer or I am authorized by the third party/employer to complete this earnings disclosure, and have done so truthfully and to the best of my knowledge. Dated: ______________________ _____________________________ Signature _____________________________ Title _____________________________ Telephone Number - 5 - EARNINGS DISCLOSURE WORKSHEET ___________________________ Judgment Debtor's Name A B C Payday Gross Disposable Date Earnings Earnings 1. ________________ $ ________________ $ ________________ 2. ________________ $ ________________ $ ________________ 3. ________________ $ ________________ $ ________________ 4. ________________ $ ________________ $ ________________ 5. ________________ $ ________________ $ ________________ 6. ________________ $ ________________ $ ________________ 7. ________________ $ ________________ $ ________________ 8. ________________ $ ________________ $ ________________ 9. ________________ $ ________________ $ ________________ 10. ________________ $ ________________ $ ________________ D E F 25% of 40 X Min. Column C Column C Wage minus 1. ________________ $ ________________ $ ________________ 2. ________________ $ ________________ $ ________________ 3. ________________ $ ________________ $ ________________ 4. ________________ $ ________________ $ ________________ 5. ________________ $ ________________ $ ________________ 6. ________________ $ ________________ $ ________________ 7. ________________ $ ________________ $ ________________ 8. ________________ $ ________________ $ ________________ 9. ________________ $ ________________ $ ________________ 10. ________________ $ ________________ $ ________________ G H I Lessor of Set off, Lien Column G Column D Adverse minus and Interest, or Column H Column F Other Claims 1. ________________ $ ________________ $ ________________ 2. ________________ $ ________________ $ ________________ 3. ________________ $ ________________ $ ________________ 4. ________________ $ ________________ $ ________________ 5. ________________ $ ________________ $ ________________ 6. ________________ $ ________________ $ ________________ 7. ________________ $ ________________ $ ________________ 8. ________________ $ ________________ $ ________________ 9. ________________ $ ________________ $ ________________ 10. ________________ $ ________________ $ ________________ - 6 - TOTAL OF COLUMN I $ ________________ *If you entered any amount in Column H for any payday(s), you must describe below either your claims, or the claims of others. For amounts claimed by others, you must both state the names and addresses of these persons, and the nature of their claim, if known. ________________ ________________ ________________ ________________ ___________ ________________ ________________ ________________ ________________ ___________ ________________ ________________ ________________ ________________ ___________ ________________ ________________ ________________ ________________ ___________ AFFIRMATION I, Name (person signing Affirmation), am the third party or I am authorized by the third party to compete this earnings disclosure worksheet, and have done so truthfully and to the best of my knowledge. Dated: _____________ _____________________________ Signature _____________________________ Title _____________________________ Telephone Number - 7 -