W/E Form Rev. 4/10/01 UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT : : : : : : Civil No. APPLICATION FOR WAGE EXECUTION Pursuant to Rule 69 of the Federal Rules of Civil Procedures and Section 52-361a of the Connecticut General Statutes, , hereby applies for the issuance of a wage execution and in support thereof makes the following representations: 1. On judgment entered in this action against for $ interest at the rate of plus costs of $ and pursuant to 28 U.S.C.§ 1961. 2. (Name of judgment debtor) has made payments and (insert name of party making application) has received (enter amount) $ pursuant to the Court’s judgment. 3. As of interest and costs is $ , the total amount of the unpaid judgment, including . Interest continues to accrue on the principal amount of the judgment at the rate of per annum. 1 American LegalNet, Inc. www.FormsWorkFlow.com 4. The last known employer of the judgment debtor, (insert name) is (indicate name and address of employer): Dated this day of , 20 . Respectfully submitted, This application of the issuance of a wage execution in the amount of the unpaid judgment including costs and interest is hereby GRANTED/DENIED. United States District Judge CERTIFICATION OF SERVICE This is to certify that a copy of the foregoing application for wage execution was sent to the defendant, , dated this day of , 20 2 American LegalNet, Inc. www.FormsWorkFlow.com .