`
`SUPERIOR COURT
`OFFICE OF THE CLERK
`
`a
`TAX WARRANT
`
`95 Washington Street
`Hartford, CT 06106
`(860) 548-2700
`
`NOTICE OF HEARING
`
`,
`
`Hearing date:
`
`‘ 10 El
`
`The Department of Revenue Services
`SIS Section 16th'Floor
`25 Sigourney Street, STE 2
`
`Hartford, CT 06106
`Time:
`2:00 PM
`
`The Office of Attorney General
`Courtroom:
`3
`55 Elm Street
`.
`Hartford, CT 06106
`Attention: Finance, Department 4
`mall?!{1 Comsltodwow 114:.
`0202 W) 6061/]7’!5“ mild/0 2d .
`@HYC» t CF 0&330
`_
`(Emmet AChmefl ”Jr,
`(for; 02): Dru/C
`.
`flumfidd Cellular“ CIT aw 3'56
`
`Docket# (3y Immflfi
`
`Commissioner ofRevenue services
`v.
`
`d
`.
`Date Notlce Sent:
`
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`I Li
`I [0
`
`NOTICE OF HEARING
`
`A Hearing on the Defendant’s Exemption and Modification Claim Request pursuant to CGS 52-
`361 a(h) and CGS 52-361b will be held at the above stated date and time. The presence of the
`partiesis required unless an agreement is reached beforehand, or the tax warrant is withdrawn.
`NOTICE TO EMPLOYER .
`
`No earning claimed to be exempt or subject to a claim for modification, may be withheld from
`any employee until ordered by the court. (See Section III on Exemption and Modification Claim
`Form)
`
`NOTICE TO BANKING INSTITUTIONS
`
`Please note that the disputed assets are being held for 45 days from the date of the exemption
`claim form was received by the banking institution or until a court order is entered.
`
`% \
`
`

`

`Exemption and Modification Claim Form
`Employer Wage Execution in Accordance Vlfith Tax Warrant
`
`E
`
`Section I (Completed by Commissioner of Revenue Services) w ’ {3% I. ,Q 3
`Address of Court ,
`Name of employer
`
`95 WaShington St
`Harford, CT 06106
`Name of debtor
`‘
`
`MATTERN CONSTRUCTION INC.
`
`Warrant number and date of issuance of warrant
`
`.
`
`RICHARD A CHENEY JR
`
`.
`
`26,1990
`
`08/19/2016 .
`
`Section II (Completed by employer upon receipt of exemption claim form)
`
`Egg gag—1,2) _
`
`Address of employer
`
`
`Address mailed to
`SE53
`awn Bushneu, ‘H-nlth lioL
`5%
`Batu—Io Cj’wSSD
`
`
`HARTFQRD JBB
`Amount to be taken out from weekly earnings ' Total amount of Wage execution
`Date of mailing
`
`
`
`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 of Issuance of Warrant 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 federallaw or state law, whichever'Is larger amount. The statutesyouremployer must follow to calculate the weekly amount that
`maybe taken _out of your wagesto comply with thewarrant arelisted below under General Statutes. if you think that your employer has
`not calculated the weekly amount correctly, you should tell your employer
`YourEarnings May Be Exempt From Execution— Your earnings may be protected from execution by statutes or regulations of the
`State ofConneCticut orofthe United States. A checklist and a description of the exemptions established by law are listed on the last page. _
`How to Claim an Exemption Allowed by Law— If you believe that your earnings are exempt by law from execution, you must fill out and
`sign Section IV— Claim of- Exemption Established by Law, 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 notify you your employer, and the Commissioner of Revenue
`Services of the date on which a hearing will be held by the court to determine theIssues raised by your claim. if this formIs received by
`the court no later than twenty (20) days from the Date of Issuance of Warrant indicated above. the employer will not begin withholding your
`earnings until after your claim is reviewed 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 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 wages), 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. The court clerk will notify you, your employer, and the Commissioner of Revenue Services of the date on which a
`hearing will be held by the court to determine theIssues raised by your claim. If this form'Is received by the court no later than twenty (20)
`‘ "daysfrom the Date of Issuanceof Warrant indicatedabove,theemployer will not begin withholding your earnings until after your claim'Is
`reviewed by the court._A claim may also be filed after the twentv (20) day period. No earnings claimed to be exempt may be withheld from
`any employee until the claim has been resoweo‘.
`
`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.
`
`"The maximum part of the aggregate weekly eamings of an individual which may be subject under this section to levy or other
`withholding forpayment of a judgment is the lesser of (1) twenty-five (25) percent ofhis disposable earnings for that week, or (2)
`the amount by which his disposable earnings for that week exceed forty (40) times the higher of (A) the minimum hourly wage
`prescribed by section 6(a)(1) of the 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.”
`
`2. 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.
`
`“Disposable eamings means that part of the earnings of an individual remaining after the deduction from those earnings of
`amounts required to be withheld for payment of federal income and employment taxes, normal retirement contributions, union
`dues and initiation fees, group life insurance premiums, health insurance premiums and federal tax levies.”
`
`Page 7
`
`R698 Rev. (06/16)
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`\ /
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`

`

`Section IV — Claim Of Exemption Established by Law (Completed by debtor upon receipt of Exemption and Modification Claim Form.)
`
`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:
`,
`-
`
`E]
`
`i get public assistance and earn wages under an incentive earnings or_similar program and my earnings are exempt from execution;
`or
`'
`i
`‘
`
`El . Other statutory exemption (List each exemption below, the amount of exemption, and the statutory authority for the exemption. Attach
`additional pages as needed.)
`'
`
`Statutory Authority
`
`Amount Claimed to be Exempt
`
`Described Claimed Exemptions Established by Law
`
`.§igrte_d._
`
`_ __ .__:__;__.._~_-.____._ _
`
`_ “Addreasfidemr.
`
`__-_
`
`*_
`
`Section V — Claim for Modification (Completed by debtor upon receipt of Exemption and Modification Claim Form)
`
`l, the debtor, ask for a modification of wage execution against me because:
`
`New Amount Requested Per Week
`'
`-
`
`0%
`
`.
`
`/Z/ fl
`
`/
`
`-
`
`I
`
`Describe wh you think you should hve less money take frm your wages
`/
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`
`.
`
`Section VI — Notice to the Clerk of Superior'Court (Completed by clerk upon receipt of the exemption claim form)
`Complete Section VI and send a file-stamped copy to:
`1., The debtor at the address of debtor indicated in Section IV or V;
`2. The employer indicated in Section II;
`.
`‘ 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.
`
`Order of the Court
`
`
`
`
`
`R698 (Rev. 06/16)
`
`Page 8
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`
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`

`

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`Dept of Revenue Services
`State of Connecticut
`25 Sigourney Street
`Hartford CT 06106-5032
`
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`
`Notice of WagelExecution
`
`””0816*“EWarrWage***54***AUCOL****
`MATTERN CONSTRUCTION INC.
`26M BUSHNELL HOLLOW RD
`BALTIC CT 06330-1404
`
`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 indicated 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 tax warrant garnishment. Include the Connecticut
`tax registration number and tax warrant number.
`
`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.
`
`' All payments must include the Debtor’s Name and Tax Warrant Number.
`
`Thank you for your cooperation.
`
`Collections Unit, Warrants
`
`Telephone:
`FAX:
`
`860—297-5883
`860—297-5843
`
`,
`
`Tax Warrant No.: 261990
`
`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 againstyou. You may be held liable to the Commissioner of Revenue Services forthe amountyou did notwithhold from
`
`your employee's wages. Additionally, the penalty for false statement is imprisonment not to exceed one year or a fine not to exceed $2,000, or both;
`
`Detach the coupon below and return it with payment in the envelope provided.
`
`
`
`Warrant Notice
`R698 (Rev. 06/16)
`
`Notice Date: 08/19/2016
`Total Amount Due: $7,477.79
`
`Enter amount enclosed $
`
`
`
`’
`
`Mail paymentwith stub to:
`DEPARTMENT OF REVENUE SERVICES
`
`-
`PO BOX 2929
`HARTFORD CT 06104-2929
`IIrm-I“”I'I'IIIHIIIII'uni'r“I'II'I'I'r'r“IL'PIHIIIIMHI
`
`
`
`" rDRS Use Only
`Make remittance payable to:
`Commissioner of Revenue Services.
`
`
`
`Write debtor‘s CT Tax Registration Number
`and tax warrant number on your check.
`
`6980015P019999
`5745336000
`1455871
`261990
`
`,
`
`
`
`[:Ij D1 D1
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`
`I
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`5E]EIEII]UCIUEICIEIDEEl‘I‘IUDUUUUUD?H???‘IEED
`
`

`

`
`
`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
`
`Tax Warrant No.: 261990
`
`Debtor CT Tax Registration Number
` Babtor name
`
`Date of termination
`
`
`
`D—eblor Social Security Number
`
`New employment
`
`
`
`W________.__—.___—_—_—————
`
`
`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.
`Signature
`
`
`
`
`Telephone number
`
`
`
`
`
`R698 (Rev. 06/16)
`
`Page 2
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