Form JD-FM-71 "Advisement of Rights" - Connecticut

What Is Form JD-FM-71?

This is a legal form that was released by the Connecticut Judicial Branch - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2014;
  • The latest edition provided by the Connecticut Judicial Branch;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-FM-71 by clicking the link below or browse more documents and templates provided by the Connecticut Judicial Branch.

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Download Form JD-FM-71 "Advisement of Rights" - Connecticut

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ADVISEMENT OF RIGHTS
COURT USE ONLY
ADRIGHT
Re: Income Withholding
JD-FM-71 Rev. 12-14
*ADRIGHT*
C.G.S. § 52-362, 15 U.S.C. § 1673
Name of Case
Docket Number
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
and you are ►
12 weeks or less past-
then ► 50% (half) of your pay
dependent child
due in your support
may be taken
If you have ►
another spouse or
and you are ►
more than 12 weeks
then ► 55% of your pay may be
dependent child
past-due in your support
taken
If you do not
another spouse or
and you are ►
12 weeks or less past-
then ► 60% of your pay may be
have ►
dependent child
due in your support
taken
If you do not
another spouse or
and you are ►
more than 12 weeks
then ► 65% of your pay may be
have ►
dependent child
past-due in your support
taken
in no case can you be left with less than 85% of the first $145 of the money that is left each week after
But ►
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
Print Form
Reset Form
ADVISEMENT OF RIGHTS
COURT USE ONLY
ADRIGHT
Re: Income Withholding
JD-FM-71 Rev. 12-14
*ADRIGHT*
C.G.S. § 52-362, 15 U.S.C. § 1673
Name of Case
Docket Number
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
and you are ►
12 weeks or less past-
then ► 50% (half) of your pay
dependent child
due in your support
may be taken
If you have ►
another spouse or
and you are ►
more than 12 weeks
then ► 55% of your pay may be
dependent child
past-due in your support
taken
If you do not
another spouse or
and you are ►
12 weeks or less past-
then ► 60% of your pay may be
have ►
dependent child
due in your support
taken
If you do not
another spouse or
and you are ►
more than 12 weeks
then ► 65% of your pay may be
have ►
dependent child
past-due in your support
taken
in no case can you be left with less than 85% of the first $145 of the money that is left each week after
But ►
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
Print Form
Reset Form
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
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