COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNITED STATES BANKRUPTCY COURT DISTRICT OF CONNECTICUT AT:::::::Index No.Calendar No.::::JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Docket No. :::WAGE EXECUTION EXEMPTION AND MODIFICATION CLAIM FORM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(The employer must complete Section III below and mail this Wage Execution Exemption and Modification Claim Form , the Wage Execution Notice to Employer , and the Wage Execution to the employee).THE PEOPLE OF THE STATE OF NEW YORK TOSECTION I (to be completed by prevailing party and attached to wage execution) ADDRESS OF COURT:UNITED STATES BANKRUPTCY COURT OFFICE OF THE CLERKGREETINGS:NAME OF JUDGMENT DEBTOR: NAME AND ADDRESS OF PREVAILING PARTY'S ATTORNEY:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomTELEPHONE NUMBER: SECTION II (to be completed by Marshal or Sheriff) DATE OF SERVICE OF WAGE EXECUTION:Your 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 result of your failure to comply., one of the Justices of theSECTION III (to be completed by employer) NAME AND ADDRESS OF EMPLOYER:Court in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)TELEPHONE NUMBER OF PAYROLL DEPT.: DATE OF DELIVERY OR MALING TO JUDGMENT DEBTOR: TOTAL AMOUNT OF WAGE EXECUTION: AMOUNT TO BE TAKE OUT FROM WEEKLY EARNINGS:Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SECTION IVNOTICE TO EMPLOYEE:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)As a result of a judgment entered against you, the attached execution has been issued against wages earned by you from the employer named above. In compliance with this execution, the employer will remove from your weekly earnings an amount of money which leaves you with the greater of forty times the federal hourly minimum wage or seventy-five percent of your disposable earnings. (The federal minimum hourly wage in effect as of October 1, 19isper hour. Forty times the federal minimum wage as of October 1, 19is $).$. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Stated below are those sections of the General Statutes which your employer must follow in determining the weekly amount that may be taken out of your wages to satisfy the wage execution. If you determine that your employer has not calculated the weekly amount correctly, you should bring this to your employer's attention.YOUR EARNINGS MAY BE EXEMPT FROM EXECUTION -Any wages earned by a public assistanceTHE PEOPLE OF THE STATE OF NEW YORK TOrecipient under an incentive earnings or similar program, are exempt from execution (Conn. Gen. Stat. 52-352(d)).HOW TO CLAIM EXEMPTION ALLOWED BY LAW -If you wish to claim that your earnings areGREETINGS:exempt by law from execution, you must fill out and sign Section V below entitled Claim of Execution and return this entire Exemption and Modification Claim to the Bankruptcy Court at the above address. This form must be received by the Bankruptcy Court no later than 20 days from the Date of Service of Execution indicated above.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,Upon receipt of this form, the Clerk of the Bankruptcy Court will notify you and (insert name of partylocated at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roommaking application) of the date on which a hearing will be held by the court to determine the issues raised by your claim.MODIFICATION OF EXECUTION -If you have reasonable cause to believe that you are entitled to aYour 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 result of your failure to comply., one of the Justices of themodification of the wage execution and wish to have the execution so modified, you must fill out Section VI below, entitled the Claim for Modification and return this entire Exemption and Modification Claim Form to the Bankruptcy Court at the above address.Court in Witness, Honorableday of, 20 County,A claim for modification may be made at any time. If you believe that you are entitled to a modification of(Attorney must sign above and type name below)Attorney(s) forthe wage execution, complete and return this form to the Bankruptcy Court no later than 20 days from the date of service of execution indicated above. No earnings subject to the claim for modification may be withheld from you until the court renders a decision on your claim. If you complete and return this form seeking a modification of the wage execution later than 20 days after the date of service of execution indicated above, your earnings will continue to be withheld until the court renders a decision on your claim.Upon receipt of this form, the Clerk of the Bankruptcy Court will notify you and the party making theOffice and P.O. Addressapplication of the date on which a hearing will be held by the court to determine the issues raised by your claim.SETTING ASIDE JUDGMENT -If judgment entered against you because of your failure to appear orTelephone No.: Facsimile No.: E-Mail Address:respond in court, you may be able to acquire relief from the judgment pursuant to the provisions of Rule 60(b) of the Federal Rules of Civil Procedure.Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .