EXEMPTION AND MODIFICATION CLAIM FORM, WAGE EXECUTION JD-CV-3a Rev. 11-15 C.G.S. § 31-58(i), 52-212, 52-350a, 52-352b, 52-361a, 52-361b, 29 U.S.C. 206(a)(1) Name and mailing address of judgment debtor (person who must pay money) or attorney of judgment debtor (To be completed by judgment creditor (person who money is paid to)) STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov *MXMPEX* MXMPEX To: Instructions To proper officer: Complete Section II below and make service on employer in accordance with the instructions on form JD-CV-3. To employer: Complete Section III below and immediately deliver to employee. Section I - Judgment Creditor (person who money is paid to) must fill out this section and attach to one copy of the wage execution application (JD-CV-3). Judicial District Name of case Housing Session Geographical Area number Name and address of court Docket number Name of judgment debtor (person who must pay money) Section II - Proper Officer must complete this section Name of proper officer Date of service of wage execution on employer Name and address of employer Section III - Employer must fill out this section and IMMEDIATELY send one copy of this form and the Wage Execution form (JD-CV-3) to the judgment debtor (General Statutes section 52-361a(d)). Total amount of wage execution Amount to be taken out from weekly earnings Telephone number of payroll department Date of delivery or mailing to judgment debtor Because a judgment entered against you, the attached execution has been issued against wages earned by you from the employer named above. Beginning twenty (20) days from the Date of Service of Wage Execution on Employer indicated above, the employer will remove from your weekly earnings an amount of money which leaves you with (a) seventy-five percent (75%) of your disposable earnings OR (b) forty (40) times the higher of the minimum hourly wage set by federal law or state law; whichever is the larger amount. On page 2 of this form are the sections of the Connecticut General Statutes which your employer must follow to figure out (calculate) the weekly amount that may be taken out of your wages to agree with the wage execution. If you think that your employer has not calculated the weekly amount correctly, you should tell your employer. Your earnings may be exempt from execution (do not have to be taken) -- Any wages earned by a person who gets public assistance under an incentive earnings or similar program are exempt from (may not be taken from you) execution. (Section 52-352b(d) of the Connecticut General Statutes). How to claim an exemption allowed by law -- If you want to claim that your earnings are exempt by law from execution you must fill out and sign the Claim of Exemption on page 2 of this form and return this exemption and modification claim form to the Superior Court at the above address. When the clerk of the Superior Court gets this form, the clerk will notify you and the judgment creditor of the date on which the court will have a hearing to figure out the issues raised by your claim. If this form is received by the court no later than twenty (20) days from the Date of Service of Wage Execution on Employer indicated above, the employer will not begin withholding (removing) your earnings from your wages until after your claim is figured out by the court. A claim may also be filed after the twenty (20) day period. No earnings claimed to be exempt may be withheld from any employee until the claim has been figured out. Modification of execution -- If you have reasonable cause to believe that you have a right to a modification (change) of the wage execution and you want to ask for a modification (to have less money taken from your wages), you must fill out the Claim for Modification on page 2 of this form and return this exemption and modification claim form to the Superior Court For Court Use Only at the address listed above. File date When the clerk of Superior Court gets this form the clerk will tell you and the judgment creditor the date on which the court will have a hearing to figure out the issues raised by your claim. If this form is received by the court no later than twenty (20) days from the Date of Service of Wage Execution on Employer indicated above, the employer will not begin withholding your earnings until after your claim is figured out by the court. A claim may also be filed after the twenty (20) day period. No earnings subject to a claim for modification may be withheld from any employee until the claim has been figured out. Setting aside judgment -- If the judgment was made against you because you did not come to court, you may, within four (4) months of the date the court made its judgment and upon belief that you have reasonable cause, ask the court to set aside the judgment entered against you and the case will begin again. A fee will be charged to you for a motion to set aside judgment. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com $ Section IV - Notice to judgment debtor (person who must pay money) $ Exemption and modification claim Section V - Claim of exemption established by law I, the Judgment Debtor (person who must pay money), claim and certify under the penalty of false statement that my earnings are exempt from execution (do not have to be taken) because: I get public assistance and earn wages under an incentive earnings or similar program and my earnings are exempt from execution, or Other statutory exemption (state exemption and statutory citation) Signed (Judgment Debtor) Date signed Name and address of judgment debtor Telephone number Section VI - Claim for modification I, the Judgment Debtor (person who must pay money), ask for a modification of the wage execution against me because: New amount requested Describe why you think you should get a modification (have less money taken from your wages) / Per week Signed (Judgment Debtor) Date signed Name and complete mailing address of judgment debtor Telephone number Section VII - Agreement to a modification The Judgment Creditor(s) (person who money is paid to) agrees to the modification of the Wage Execution claimed Signed (Judgment Creditor(s) or Attorney)) Name of Judgment Creditor(s) or Attorney Date Section VIII - Notice of hearing on exemption / modification claim Date of hearing Time of hearing Courtroom __. M. Section IX - Order of court It is ordered that: By the Assistant Clerk Signed (Judge, Magistrate, Assistant Clerk) By order of the court Date