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Connecticut Advisement of Rights Form


Connecticut Advisement of Rights Form
Connecticut Advisement of Rights Form
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).
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:
ADVISEMENT OF RIGHTS
Re: Income Withholding
JD-FM-71 Rev. 11-12
C.G.S. § 52-362, 15 U.S.C. § 1673
This is to attest that the above document was signed in my presence.
Check the box below if the parties have completed the "Agreement" on the back/page 2 of this form.
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/Title
Signature
ADRIGHT
COURT USE ONLY
Name of Case Docket Number
"Agreement that Immediate Income Withholding Order not be Effective Immediately" completed on back/page 2.
*ADRIGHT*
If you have another spouse or
dependent child
and you are 12 weeks or less past-
due in your support
then 50% (half) of your pay
may be taken
If you have another spouse or
dependent child
and you are more than 12 weeks
past-due in your support
then 55% of your pay may be
taken
If you do not
have
another spouse or
dependent child
and you are 12 weeks or less past-
due in your support
then 60% of your pay may be
taken
If you do not
have
another spouse or
dependent child
and you are more than 12 weeks
past-due in your support
then 65% of your pay may be
taken
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.
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Connecticut Advisement of Rights Form
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