ADVISEMENT OF RIGHTS Re: Income Withholding JD-FM-71 Rev. 12-14 C.G.S. § 52-362, 15 U.S.C. § 1673 COURT USE ONLY ADRIGHT *ADRIGHT* Docket Number Name of Case 1. You have the right to give the court any evidence to show why the court should not order that money be taken out of your pay or income starting immediately. 2. Not all of your income can be withheld: The only money that may be taken out of your pay for support is the money that is left after you pay required federal, state and local income taxes, employment taxes, normal retirement contributions, union dues and initiation fees and group life and health insurance premiums. And only some of the leftover money can be taken out. Having other dependents (or not) and being past-due on your support payments can affect the amount withheld. The chart below shows how much can be taken from your pay after money is taken out for required federal, state and local income taxes, employment taxes, normal retirement contributions, union dues and initiation fees and group life and health insurance premiums: If you have another spouse or dependent child another spouse or dependent child another spouse or dependent child another spouse or dependent child and you are 12 weeks or less pastdue in your support more than 12 weeks past-due in your support 12 weeks or less pastdue in your support more than 12 weeks past-due in your support then 50% (half) of your pay may be taken 55% of your pay may be taken 60% of your pay may be taken 65% of your pay may be taken If you have and you are then If you do not have If you do not have and you are then and you are then But in no case can you be left with less than 85% of the first $145 of the money that is left each week after money is taken out for required federal, state and local income taxes, employment taxes, normal retirement contributions, union dues, initiation fees and group life and health insurance premiums. 3. You have the right to tell the court that money is being taken out of your pay for required federal, state and local income taxes, employment taxes, normal retirement contributions, union dues and initiation fees and group life and health insurance premiums. You can also tell the court about other state or federal exemptions that apply to income withholding orders. 4. The amount that will be taken out of your pay or income will be calculated by the person or company that pays you (your employer) based on information given by the court. If you believe that an incorrect amount of your income is being withheld because of incorrect information being given to the person or company that pays you and you would like the amount withheld changed, you must ask for a court hearing. 5. You can also ask the court to change your support order, or tell the court that you should not have to pay support, by filing a motion with the court (use form JD-FM-174). I certify that this document was read to me or read by me in a language that I understand. I have been given a copy of this statement. Signature Print Name Date signed This is to attest that the above document was signed in my presence. Signature/Title Print Name Date signed Check the box below if the parties have completed the "Agreement" on page 2 of this form. "Agreement that Immediate Income Withholding Order not be Effective Immediately" completed on page 2. JD-FM-71 Rev. 12-14 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Agreement that Income Withholding Order not be Effective Immediately Name of Case Docket Number The parties signing below agree that the court order a contingent income withholding to be effective only on accrual of a delinquency in an amount greater than or equal to thirty days' obligation. Obligor Print Name Date signed Obligee Print Name Date signed Other Print Name Date signed Other Print Name Date signed Witness Print Name Date signed Witness Print Name Date signed ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. JD-FM-71 Rev. 12-14 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com