COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): Index No. FOR COURT USE ONLY WG-026 : : : : : Calendar No. Plaintiff(s) TELEPHONE NO: JUDICIAL SUBPOENA -against- NO.: FAX ATTORNEY FOR STATE TAXPAYER/RESPONDENT: NAME OF COURT: STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: Defendant(s) BRANCH NAME: : . . . . . .OF. (Name):. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... APPLICATION TAXPAYER/RESPONDENT CLAIM OF EXEMPTION AND FINANCIAL DECLARATION THE PEOPLE OF THE STATE OF NEW YORK NAME OF STATE TAX AGENCY: CASE NUMBER: TAX AGENCY NUMBER: TO (Copy the information required above from the Application for Earnings Withholding Order for Taxes (form WG-020). The top left space is for your or your attorney's name and address.) GREETINGS: 1. I need the following earnings to support myself or my family (check and complete item a or b): each pay period. b. a. All earnings. $ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before me my attorney shown above at the address following (specify): , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned 25 percent minimum withholding, I amas a witness in this action on to be withheld from my earnings during the date, to testify and give evidence willing for the following amount the part of the 3. In addition to the 2. Please send all papers to withholding period: a. None b. Withhold: $ each pay period. 4. a. I am paid Your daily weekly every two weeks twice a month monthly. failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a b. My gross pay is: $ per pay period. result of your failure to comply. c. My take-home pay is: $ per pay period. d. My payroll deductions are (item and amount): Court in Witness, Honorable County, , one of the Justices of the , 20 day of 5. The following persons depend, in whole or in part, on me for support: Name a. b. Age sign above and type name below) Relationship to me (Attorney must Monthly income and its source Myself Attorney(s) for c. d. e. 6. The earnings of others listed in item 5 are now subject to wage assignments and Earnings Withholding Orders as follows (specify): Office and P.O. Address Form Adopted for Mandatory Use Judicial Council of California WG-026 [Rev. January 1, 2007] Telephone No.: Facsimile No.: E-Mail Address: CLAIM OF EXEMPTION AND FINANCIALMobile Tel. No.: DECLARATION (Wage Garnishment-State Tax Liability) Page 1 of 2 Code of Civil Procedure, §§ 706.051, 706.076 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com WG-026 APPLICATION OF (Name): CASE NUMBER: TAXPAYER/RESPONDENT 7. My monthly expenses are as follows: a. Rent or house payment and maintenance . . . . . . . . . . . . . . . . . . $ b. Food and household supplies . . . . . . $ c. Utilities and telephone . . . . . . . . . . . $ d. Clothing . . . . . . . . . . . . . . . . . . . . . . $ e. Laundry and cleaning . . . . . . . . . . . $ f. Medical and dental payments . . . . . .$ g. Insurance (life, health, accident, etc.) . . . . . . . . . . . . . . . . . . $ h. School, child care . . . . . . . . . . . . . . . $ i. Child, spousal support (prior marriage) . . . . . . . . . . . . . . . . $ 8. List payments on installment and other debts. Creditor's name j. Entertainment and incidentals . . . . k. Transportation and auto expenses (insurance, gas, repair) . . . . . . . . . . l. Installment payments (insert total and list below in item 8) . . . . . . m. Other (specify): . . . . . . . . . . . . . . . . $ $ $ $ TOTAL MONTHLY EXPENSES (add a through m) . . . . . . . . . . . . . . . . $ Continued on Attachment 8. For Monthly payment Balance 9. What do you own? (State value.) a. Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b. Checking, savings and credit union accounts, etc. (list institutions): (1) $ (2) $ $ (3) $ (4) c. Cars, other vehicles, and boat equity (list make, year of each): (1) $ (2) $ $ (3) 10. d. Real estate equity (addresses): . . $ e. Other personal property (jewelry, furniture, furs, stocks and bonds, etc. List separately): Total for item e: . . . $ An Order Assigning Salary and Wages (for support) is now in effect as to my earnings. The amount payable under that order monthly. is: $ 11. Other facts that support this Claim of Exemption are (describe unusual medical needs, school tuition, expenses for recent family emergencies, or other unusual expenses to help the judge understand your budget): Continued on Attachment 11. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: (TYPE OR PRINT NAME) (SIGNATURE OF TAXPAYER) File this form with the clerk of the court and mail a copy to the tax agency as soon as possible. Keep a copy and take it with you to the court hearing. If you wish to obtain the advice of an attorney, you should do so at once. WG-026 [Rev. January 1, 2007] CLAIM OF EXEMPTION AND FINANCIAL DECLARATION (Wage Garnishment-State Tax Liability) Page 2 of 2