- Exemption and Modification Claim Form
`Employer Wage- Execution in Accordance Vlfith Tax Warrant
`Section | (Completed by Commissioner, of Revenue Services) w_. ,; , Q _. (a "3
`Address of Court .
`Name of employer
`.95 Washington-3t
`, MATTERN CONSTRUCTION INC.
`Harford, CT 06106
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`Name of debtor
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`Wanant number and date of issuance of wanant
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`RICHARD A CHENEY JR
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`25.19.99. ..
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`08/19/2016.
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`section II (Completed by employer upon receipt ofexemption claim form)
`Complete Section II and send one copy of this form and the tax warrant to the debtor in accordance with Conn. Gen. Stat. §52—36 a
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`Address of employer
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`SEE it: 2015
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`HARTFQRD as.
`Eat/+10 (2’09330
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`- Total amount of Wage'execution
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`Dat'e'of mailing
`Amount to be taken out from weekly earnings
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`$2§IU.
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`Section III — Noticeto Debtor ‘
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`The attached tax warrant has been issued against wages earned by you from-(the employer named-above. Beginning twenty (20) days
`from the Date ofissuance of Warrant indicatedrabove. 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 heurly wage
`set by federal'law or‘state law.- WhicheVer'isl'arger‘ambtintfil’he statutes‘yourtemployer.mustitdll’ow to calculate the weekly amount that
`maynbértakenput of‘yguL-yvages‘=to,\co‘gpply.lll(th thwegwartant are ‘listed‘belpyg: under General'iStatult'es. if youthink that your employer has
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`not calculated therweeklyamoun
`rreptly; you shoul'd‘t'ell your’employeir.~.;
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`YouFEafnings MayuB‘ejExerript‘ Fr‘om‘Execution‘l-Ydurjearnings ‘r’nay befprfotédted‘frdm "executlon by statutes or- regulations of the
`State of‘Connecticut giietlthe United States. A checklist="_a‘nd.a=de‘s‘cription of'the exemptionsestablished by law are listed on the last page. .
`How to Claim an Exemption Allowed by __l.aw —.If you believe-that your earnings are exempt by law from execution,_ydu must fill out and
`sign Section-N:— Claim.ofi£xemgtiopEstablished byLaw, below and mailvor‘deliyer this Exemption And Modification-Claim Eorm to the ,
`Superior Court at the address of‘court'indic‘ated aboiie‘: TheiTcdu‘tt clerk Will=ncjtify yOu, your employer, and the Cdmmi‘ssioner ottRevenue
`Services of thedate on which a hearing will beheld by the court to determin'etheiSsues raised by your claim.. If this form .is re'Ceived' by
`the court no later than twenty (20) days from the Date ofIssuance of Warrantindicated above, the employer Will not begin withholding your
`earnings until after your claim is reviewedby-the court. Aclaim-may (also befiledafter the twenty (20) day period.- Noearnings 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 thaty0u have a right to a modification (change)
`of the wage execution and you want to request a modification (to have less money taken fromyour wages), you muSt fill out Section V
`— Claimfor Modification, below and mail or deliver this Exemption And Modification Claim Form to the Superior COurt at the'address of
`court indicated above. The court clerk will netify'you, youremployer,‘ and the Commissioner Of R'eVenue'S'érvices of the‘date‘on-which a
`hearing will be held by the Co’t‘lrt to’determi’ne the issues raised byer claim. If this form is'receivediby the court no la’terthan twénty'(20)
`days from the Date of Issuance ofWanant indicated above; the empIOyerlwillnot begin Withholding your earnings until after ydur claim is
`reviewed by the court._A claim mayalso 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 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 ofajudgment is the lesserof(1) twenty-five (25) percent ofhis disposable earnings for that 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 efi'ect 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
`7 of your wages which cannot be included in'your total earnings when figuring cut (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 fmm 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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`. R695 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 certify 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] 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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`E] 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 to beExempt
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`Described Claimed Exemptions Established by Law
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`Signed .
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`Date
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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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`(9% V
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`l, the debtor. ask for a modification of wage execution against mebecause.
`, New Amount Requested Per Week
`. Describe wh you think you should h ve less money take frm your wages
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`1 fife/450%dflminw fin" kz 1:149,04 01w (ma/b
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`Section VI-Notice to the Clerk of SuperiorCourt (Completedby clerk upon receiptof the exemption claim form)
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`Complete Section VI and send a file-stamped copy to:
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`The debtor at the address of debtor indicatedIn 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 Sigourney 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
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`Time of hearing...
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`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. 06/16)
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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 Services (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.
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`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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`TaxWarrant No.: 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 amount you did notwithhold 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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`FE a?“
`W
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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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`F 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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`698°°15P019999
`5745336000
`1455871
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`261990
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`DJ ':[:| CE]
`Mail paymentwithstubto:
`DEPARTMENT OF REVENUE SERVlCES m
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`PO BOX 2929
`HARTFORD CT 06104-2929
`IIII'I'I”'I'I'IIIIIIIIII'-III'I“I'I""I'I'I'|'-'I-lmlll--'I|
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`EDDUBDDUUDDDEEl‘fi‘iDDUflUUUU?H???‘IEED
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`44 .'.<—.
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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 CT Tax Registration Number
` Debtor name
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`Date of termination
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`fibtor Social Security Number
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`New employment
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`l 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
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`Title
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`Telephone number
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`R698 (Rev. 06/16)
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`Page 2
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