STATE OF MINNESOTA |
DISTRICT COURT |
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COUNTY OF
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JUDICIAL DISTRICT |
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(Judgment Creditor) |
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against |
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EXECUTION EXEMPTION |
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NOTICE AND NOTICE OF |
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(Judgment Debtor) |
INTENT TO LEVY ON EARNINGS |
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WITHIN TEN DAYS |
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(Third Party) |
DATED:
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(Attorney for Judgment Creditor) |
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Address |
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Telephone |
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Program |
Case Number (if known) |
County |
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Program |
Case Number (if known) |
County |
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Correctional Institution |
Location |
DATE:
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Judgment Debtor |
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Address |
STATE OF MINNESOTA |
DISTRICT COURT |
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COUNTY OF
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JUDICIAL DISTRICT |
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FILE NO.
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(Judgment Creditor) |
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against |
NOTICE OF LEVY ON |
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EARNINGS AND DISCLOSURE |
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(Judgment Debtor) |
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and |
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(Third Party) |
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Attorney for the Judgment Creditor |
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Address |
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(...)
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Phone Number |
Yes
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No
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Yes
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No
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3. |
COLUMN A. |
Enter the date of judgment debtor's payday. |
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4. |
COLUMN B. |
Enter judgment debtor's gross earnings for each payday. |
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5. |
COLUMN C. |
Enter judgment debtor's disposable earnings for each payday. |
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6. |
COLUMN D. |
Enter 25 percent of disposable earnings. (Multiply Column C by .25.) |
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7. |
COLUMN E. |
Enter here 40 times the hourly federal minimum wage ($.......) times the number of work weeks included in each payday. (Note: If a pay period includes days in excess of whole work weeks, the additional days should be counted as a fraction of a work week equal to the number of work days in excess of a whole work week divided by the number of work days in a normal work week.) |
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8. |
COLUMN F. |
Subtract the amount in Column E from the amount in Column C, and enter here. |
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9. |
COLUMN G. |
Enter here the lesser of the amount in Column D and the amount in Column F. |
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10. |
COLUMN H. |
Enter here any amount claimed by you as a setoff, defense, lien, or claim, or any amount claimed by any other person as an exemption or adverse interest which would reduce the amount of earnings owing to the judgment debtor. (Note: Any indebtedness to you incurred within ten days prior to your receipt of the first execution levy on a debt may not be set off against the earnings otherwise subject to this levy. Any wage assignment made by the judgment debtor within ten days prior to your receipt of the first execution levy on a debt is void.) |
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You must also describe your claim(s) and the claims of others, if known, in the space provided below the worksheet and state the name(s) and address(es) of these persons. |
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Enter zero in Column H if there are no claims by you or others which would reduce the amount of earnings owing to the judgment debtor. |
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11. |
COLUMN I. |
Subtract the amount in Column H from the amount in Column G and enter here. This is the amount of earnings that you must retain for the payday for which the calculations were made. The total of all amounts entered in Column I is the amount to be remitted to the attorney for the judgment creditor. |
Dated:
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Signature |
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Title |
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Telephone Number |
A |
B |
C |
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Payday Date |
Gross Earnings |
Disposable Earnings |
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$
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$
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10. |
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D |
E |
F |
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25% of Column C |
40 X Min. Wage |
Column C minus Column E |
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10. |
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G |
H |
I |
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Lesser of Column D and Column F |
Setoff, Lien, Adverse Interest, or Other Claims |
Column G minus Column H |
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3. |
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10. |
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TOTAL OF COLUMN I |
$
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Title |
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Dated:
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(...)
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Signature |
Phone Number |
STATE OF MINNESOTA |
DISTRICT COURT |
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COUNTY OF
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JUDICIAL DISTRICT |
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FILE NO.
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(Judgment Creditor) |
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against |
NOTICE OF LEVY ON |
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EARNINGS AND DISCLOSURE |
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(Judgment Debtor) |
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and |
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(Third Party) |
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Attorney for the Judgment Creditor |
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Address |
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(...)
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Phone Number |
Yes
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No
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Dated:
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Signature |
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Title |
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Telephone Number |
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EARNINGS DISCLOSURE WORKSHEET |
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Debtor's Name |
A |
B |
C |
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Payday Date |
Gross Earnings |
Disposable Earnings |
1. |
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$
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$
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2. |
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10. |
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D |
E |
F |
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Either 50, 55, 60, or 65% of Column C |
Setoff, Lien, Adverse Interest, or Other Claims |
Column D minus Column E |
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4. |
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5. |
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6. |
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8. |
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10. |
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TOTAL OF COLUMN F |
$
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Signature |
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Dated:
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(...)
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Title |
Phone Number |
Official Publication of the State of Minnesota
Revisor of Statutes