Fill and Sign the Wage Execution Proceedings Form

Signed (Assistant Clerk of said court) Execution To: Any Proper Officer Whereas the above-named Judgment Creditor(s) recovered judgment against the above-named Judgment Debtor(s) for the above Amount of Judgment, Costs and Fees as appears of record, whereof execution remains to be done on the Total Shown in line 8 above, And Whereas , pursuant to statute, the said court entered an order that said judgment be paid in installment payments, And Whereas , the said Judgment Debtor(s) failed to comply with said order for installment payments, as appears of record by application of said Judgment Creditor(s) moving that this execution issue on said Totalin line 8 above. WAGE EXECUTION PROCEEDINGS APPLICATION, ORDER, EXECUTION JD-CV-3 Rev. 10-09 General Statutes §§ 31-58(j), 52-350a, 52-361a,52-356d, 29 U.S.C. 206(a)(1) STATE OF CONNECTICUT SUPERIOR COURT Instructions 1. Prepare original and four copies. 2. Attach form JD-CV-3a to one copy of this form. 3. Present original and 3 copies to clerk of court. 4. Keep one copy for your file. Address of court (Number, street, and town) Date of judgment 1. Issue execution by signing original and 2 copies. 2. Retain one copy for court file 3. Enter any court ordered limitation at the bottom of section II on page 2. 1. Leave one signed copy with employer.2. Make return on signed original. 3. Leave one copy of Modification and Exemption Claim form (JD-CV-3a) with employer and fill in "Date of Service" on form. $ Docket number (Fold) Name and mailing address of Judgment Creditor or Attorney (To be completed by Judgment Creditor or Attorney) Judgment Creditor or Attorney ClerkProper Officer Commencement date (Employers must pay amount of execution calculated on page 2 of this form) Name and address of employer of Judgment Debtor (If known) Telephone number of employer (if known) Signed (Judgment Creditor or Attorney) Telephone number Application Page 1 of 2 G.A. J.D. Amount of (weekly, monthly, or other) payments ordered Date signed APPWEX WAGEEX Name(s) and address(es) of Judgment Debtor(s) Name(s) and address(es) of Judgment Creditor(s) 5. Total amount unpaid (Subtract 4 from 3) 1. Amount of judgment (Include where applicable, prejudgment interest and attorney's fees) 2. Amount of costs and fees 3. Total amount of judgment, costs and fees (Add 1 and 2) 4. Total amount paid (If any) 6. Application fee for wage execution (If not waived by the court) 8. Total of lines 5, 6 and 7 On (Date) For Court Use Only File date WAGE EXECUTION PROCEEDINGS Housing Session These are, therefore, by authority of the State of Connecticut, to command you, that of any wages due any said Judgment Debtor as may not exceed the Amount of Execution calculated on page 2 of this form, within your precincts, you cause to be levied, paid, and satisfied unto the said Judgment Creditor(s), with postjudgment interest as ordered by the Court, if applicable, plus the application fee and other Court ordered postjudgment costs and fees, and your own fees. Make service hereof within one year of this date, and due return hereof with your doings thereon, within thirty days from satisfaction hereof. Employer: See Page 2 for instructions 7. Other Court ordered postjudgment costs and fees Check if applicable Postjudgment interest was ordered by the Court Computation Of Employee's Disposable Earnings Important Notice To Employer You are being served with a wage execution, a court order requiring you to withhold non-exempt wages from a person employed by you. This execution is being served on you because your employee, the Judgment Debtor (on page 1), has had a judgment entered against him/her by the Superior Court requir ing him/her to pay judgment, costs and fees to the Judgment Creditor (on page 1) and has not made payment of the total amount of the judgment plus any costs and fees as shown on page 1. This notice is to inform you of the actions you must take in order to comply with the law regarding wage executions. Please read each section carefully. I. You must notify the employee — Your employee has certain legal rights which may allow him/her to request the court to change or stop this execution upon his/her wages. A notice of his/her rights and how to get a hearing in court is attached to the second copy of the wage execution given to you by the officer. You must complete your portion of the wage execution and your portion of the exemption and modification claim form and deliver or mail, postage prepaid, a copy of these papers to your employee immediately so that your employee can make any claims allowed by law. Court ordered limitation (If any, to be entered by clerk) II. Execution not effective for 20 days — This execution is not effective until after 20 days from the day the officer served these papers on you. No money should be deducted from your employee's wages until the first wages you pay to your employee after the 20-day period ends. If your employee elects within the 20-day period to make a claim to the court that his/her wages are partially or totally exempt from execution to pay this judgment or he/she seeks to have the amount of this execution changed, wages are not to be withheld from the employee until the court decides the claims or determines the rights of your employee in this case. If you are not notified that your employee has filed papers with the court, the execution is to be enforced after 20 days from the date of service on you. III. Stay of execution — No earnings claimed to be exempt or subject to a claim for modification may be withheld from any employee until determination of the claim by the court. IV. Only one execution issued under section 52-361a of the General Statutes is to be satisfied at a time — You must make deductions from your employee's wages and pay over the withheld money against only one execution issued under General Statutes section 52-361a at a time. If you are served with more than one execution issued under General Statutes section 52-361a against this employee's wages, the executions are to be satisfied in the order in which you are served with them. (Income withholdings and voluntary wage deductions for support of a family, if there are any, must be paid before this execution. Family support income withholdings and voluntary wage deductions are issued on Form JD-FM-1.) "Disposable Earnings" means that part of the earnings of an individual remaining after the deduction from those earnings of amo unts to be withheld for payment of federal income and employment taxes, normal retirement contributions, union dues and initiation fees, g roup life insurance premiums, health insurance premiums, and federal tax levies. Section I. 1. Employee's gross compensation per week.................................................................................... ..... 2. Federal income tax withheld.................................................................. 3. Federal employment tax........................................................................ 4. Normal retirement contribution.............................................................. 5. Union dues and initiation fees............................................................... 6. Group life insurance premium................................................................ 7. Health insurance premium..................................................................... 8. Other federal tax levies.......................................................................... 9. Total allowable deductions (Add lines 2-8)............................................ 10. Weekly Disposable Earnings (Subtract line 9 from line 1)..................................................... To be calculated by employer Column 1 Column 2 A-1. Weekly disposable earnings (from line 10 above) $ Computation Of Employee's Disposable Earnings $ $ $ $ $ A-2. 25% of disposable earnings for week Amount of Execution (Lesser of the two amounts in column 2 subject to any court ordered limitation set forth in the box below if a lesser amount.) B-1. Weekly disposable earnings (from line 10 above) Forty times the HIGHER of the current federal min- imum hourly wage OR state full minimum fair wage. Amount by which line B-1 exceeds B-2 B-2. V. Maximum amount deducted — The maximum amount which can be legally withheld from your employee's wages is 25% of his/her disposable earnings for each week. The amount to be withheld to pay this execution may be less than 25%, but it can never be more. The computations you complete below will allow you to calculate the exact amount which should be withheld from this employee's wages. Unless the court orders that this execution is to be for a smaller amount, you must withhold and pay over the maximum amount which you figure out using the computations below. Your employee has a right to request the court to reduce the amount withheld, but until you receive notice that the court has agreed to allow the amount to be reduced, you must withhold the maximum amount. VI. Your duty to comply with this execution — You have a legal duty to make deductions from your employee's wages and pay any amounts deducted as required by this execution. If you do not, legal action may be taken against you. If you are found to be in contempt of a court order, you may be held liable to the Judgment Creditor for the amounts of wages which you did not withhold from your employee. VII. Discipline against your employee — You may not discipline, suspend or discharge your employee because this wage execution has been served upon you. If you do unlawfully take action against your employee, you may be liable to pay him all of his lost earnings and employment benefits from the time of your action to the time that the employee is reinstated. The law allows you to take disciplinary measures against the employee if you are served with more than 7 wage executions against his/her wages in any calendar year. Page 2 of 2 Section II. JD-CV-3 Rev. 10-09