' Exemption and Modification Claim-Form
`Employer Wage- EXecution in Accordance WIth Tax Warrant
`Section I (Completed by Commissioner, of Revenue Services) w, ; ’ $5 .9 40 3
`Address of Court _
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`Name of employer
`.95 Washington St
`MATTERN CONSTRUCTION INC.
`Harford, CT 06106
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`Name of debtor
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`Wanant number and date of issuance of warrant
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`RICHARD A CHENEY JR
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`72519.ng ..
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`08/19/2016.
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`Section II (Completed by employer upon receipt ofexemption claim form)
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`Complete Section II and send one copy of this form and the tax warrantto the debtor in accordance with Conn. Gen. Stat. §52—36 a
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`Address of employer
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`SEE its 2015
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`Date‘of mailing
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`‘ Total amount of Wage'execution
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`Amount to be taken out from weekly earnings
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`Section III — Notice to Debtor ‘
`The attached tax warrant has been issued against wages earned by you from-the employer named-above. Beginning twenty (20) days
`from the Date oflssuance of Warrant indicated above, the employer will remove from your weekly earnings an amount of money which-
`leaves you with '(a)‘severity-five'percent (75%);of your disposable earnings or (b_) forty (40) times thehigher of the minir’nUm h0urly wage
`set by federal-law or’state raw, WhicheVer"is larger "amofint..?l‘he statuteskyourternployer.must'fdllow to calculate the weekly amount that
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`maybe taken-put of,ygurcwagestfiqgfili‘plytwith the(wfarr.ant are‘listedpeloyy; udder GeneraFStatut'es. If you think that your employer has
`not calculated therwee‘klyamountjcorrectly, you shoiild‘te‘ll your‘employer,-.,_ ..
`YouFEagnings May, Be,‘Exempt‘Frbrn“Exchtion‘1-Ytiurjearnings- may bejprfo‘tected‘frcim "execution by statutes or regulations of the
`State of‘Connedticut grio‘flthe Uriited States. A checklist'a‘ndsa‘de‘scription of'the eXemptions.e§tablished by law are listed on the last page. ‘
`How to Claim an Exemption Allowed by _l_.aw —lf you believe-that your earnings are exempt by law from execution,y0u must fill out and
`sign Section'lVfr Claim‘ol’tlExemgtr‘onEstablished bnyaw, below and mail-nondeliyer this Exemption And Modificatioh’C/aim Eorm to the .
`Superior Court at the address ofocurt’indic'at'ed aboiie‘: Thel‘cdurt' clerk 'Will'=no'tify you, your employer, and the Commissioner otrRevenue
`Services of the-date on which a hearing will beheld by the court to determinetheissues raised by yoUr claim.. If this form .is received by
`the court no later than twenty (20) days from the Date ofIssuance of Wanantindicated above, the employer Will not begin withholding your
`earnings until after your claim is reviewed’bythe court. A claim- may (also be»filed.~after_the twenty (20) day.period.- No-earnings claimedto
`be exempt may be withheld from any employee until the claim has been resolved?
`How to Claim a 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 request a modification (to have less money taken from_your.wag,es), you must fill out Section V
`— Claim‘for Modification. below and mail or deliver this Exemption And Modification Claim Form to the Superior Court at the address of
`court indicated above. Thecourt clerk will notify'y'ou, your'employ'er,‘ and the Commissioner Of ReVenueServices of thedate 'on'which a
`hearing will be held by the court to’determi'ne the issues raised 'by'your claim. If this form is'receivediby the ecurt no laterthan twenty‘(20)
`days from the Date of Issuance ofWarrant indicated abdve', the empIOyer-will-not begin Withholding your earnings until after your claim is
`reviewed by the court._A claim mayalso be filed after the twenty (20) day'period. No earnings cl‘aimed'to be exempt may be withheld from
`any employee until the claim has been resolved.
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`General Statutes
`1. The following is the part of Conn. Gen. Stat. §52-361a(f) which identifies what part of your wages can be removed by the employer
`and given to the judgment creditor.
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`. “The maximum part of the aggregate weekly earnings of an individual which may be subject under this section to levy or other
`withholding forpayment ofajudgmentis the lesserof(1) twenty-five (25) percent ofhis disposable earnings forthat week, or (2)
`the amount bywhich his disposable earnings for that week exceedforty (40) times the higher of (A) the minimum hourly wage
`prescribed by section 6(a)(1) ofthe Fair Labor Standards Act of 1938, 29 U.S. C. Section ,206(a)(1), or (B) the full minimum fair
`wage established by subsection (i) of section 31-58, in effect at the time the earnings are payable.”
`'The following is the part of Conn. Gen. Stat. §52-350a(4) which defines disposable earnings and, in doing so, explains what parts
`of your wages which cannot be included in'your total earnings when figuring out (calculating) the weekly amount which is subject to .
`’ execution.
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`“Disposable earnings means that part of the earnings of an individual remaining after the deduction from those earnings of
`amounts required to be withheld forpayment offederal income and employment taxes, normal retirement contributions, union ,
`dues and initiation fees, group life insurance premiums, health insurance premiums and federal tax levies.”
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`2.
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`R699 Rev. (06/16)
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`Section IV — Claim of Exemption Established by Law (Completed by debtor upon receipt of Exemption and Modification Claim Form.)
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`l, the debtor named above claim and ceItify under the penalty of false statement that my earnings are exempt from execution (do not
`have to be taken) because.
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`[I | get public assistance and earn wages under an incentive eamings orsimilar program and my earnings are exempt from execution;
`or
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`I] Other statutory. exemption (List each exemption below, the amount of exemption, and the statutory authority for the exemption. Attach
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`additional pages as needed.)
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`Statutory Authority
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`Amount Claimed tobeExempt
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`Described Claimed Exemptions Established by Law
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`Signed.
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`Address "of debtor
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`Section V — Claim for Modification (Completed by debtor upon receipt of Exemption and Modification Claim Form)
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`l, the debtor. ask for a modification of wage execution against me' because:
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`, New Amount Requested Per Week
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`Describe wh you think you should h ve less money take 'frm your wages
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`Section VI—Notice to the Clerk of SuperiorCourt (Completedby clerk upon rewipt ofthe exemption claim form)
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`Complete Section VI and send a f le-stamped copy to:
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`The debtor at the address of debtor indicated'In Section IV or V;
`2. The employer indicated'In Section II;
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`' 3. The Department of Revenue Services Office of Counsel, 19th Floor, 25_ Sigoumey Street Ste 2, Hartford CT 06106; and
`4. The Office of the Attorney General Attention. Finance, Department 4, 55 Elm Street, Hartford CT 06106.
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`Date of hearing
`TIme of hearing,.,
`Courtroom number
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`Order of the Court
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`‘Judge'
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`Date ,
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`R698 (Rev. 06l16)
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`Page 8
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`Dept of Revenue Services
`State of Connecticut
`25 Sigourney Street
`Hartford CT 06106—5032
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`Notice of Wage Execution
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`“"0816***EWarrWage***54*“AUCOL****
`MATTERN CONSTRUCTION INC.
`26M BUSHNELL HOLLOW RD
`BALTIC CT 06330-1404
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`The Department of Revenue Sen/ices (DRS) has issued a tax warrant to garnish the wages of one of your employees (debtor). In accordance
`with Conn. Gen. Stat. §12—35, that debtor is- identified and the applicable 'Connecticut'tax registration number or Social Security Number
`(SSN) and tax warrant number are indiéated on the attached tax warrant.
`If the debtor has a current garnishment in effect, other than child support, keep the tax warrant and send DRS a letter detailing the
`remaining time on the current garnishment and the possible start date for the attached taxwarrant garnishment. Include the Connecticut
`tax registration number and tax warrant number.
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`Under Conn. Gen. Stat. §52~361, Child Support Orders should be calculated independently of this tax warrant.
`On any Child Support Arrearage Order, the amount of the arrearage deduction should be subtracted from the 25% of the disposable
`earnings with the difference submitted to the garnishment(s) in the order of service.
`If the debtor is not an employee or has been terminated, please complete the back side of this form and return this entire Notice of Wage
`Execution to the address indicated.
`To ensure payments are correctly applied, you must use the attached coupon for your payment.
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`' All payments must include the Debtor’s Name and Tax Warrant Number.
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`Thank you for your cooperation.
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`Collections Unit, Warrants
`Telephone:
`860-297-5883
`FAX:
`860-297-5843
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`Tax Warrant No.2 261990
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`Important
`You have a legal duty to make deductions from your employee’s wages and to pay any amounts deducted as required by this tax warrant. If you do
`not, legal action may be taken against you. You may be held liable to the Commissioner of Revenue Services for the amountyou did not withhold from
`your employee's wages. Additionally, the penalty forfalse statement is imprisonment not to exceed one year or a fine not to exceed $2,000, or both;
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`Detach the coupon below and return it with payment in the envelope provided.
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`Warrant Notice
`R698 (Rev. 06/16)
`Notice Date: 08/19/2016
`Total Amount Due: $7,477.79
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`Enter amount enclosed $
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`* .r DRS Use Only @
`Make remittance payable to:
`Commissioner of Revenue Services.
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`Write debtor's CT Tax Registration Number
`and tax warrant number on your check.
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`6980015P019999
`5745336000
`1455871
`251990
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`Mail paymentwithstubto:
`DEPARTMENT OF REVENUE SERVICES m
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`PO BOX 2929
`HARTFORD CT 06104-2929
`IIII'l-lml'I'lllIllIIII"III'I”l'|'-'-|'I'I'I'-'|-lmlll'-'|I
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`EUUDUDDUUUDDEELH‘IDDUDDUUUTH77?‘|EEU
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`4..» J.w1.'-l—.
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`Tax Warrant No.: 261990
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`Please complete this if the debtor is not an employee or has been terminated and return this page Notice of Wage Execution to:
`Department of Revenue SerVices
`State of Connecticut
`Collections Unit, Warrants
`25 Sigourney St.
`Hartford CT 06106-5032
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` Debtor name
` Ebtor Social Security Number Date of termination
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`Debtor CT Tax Registration Number
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`New employment
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`I declare under the penalty of false statement that the above information is to the best of my knowledge and belief, true. complete. and correct.
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`Signature
`Date
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`Telephone number
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`R698 (Rev. 06/16)
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`Page 2
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