COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. :
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
Index No.
FOR COURT USE ONLY
WG-026
: Plaintiff(s)
TELEPHONE NO:
Calendar No.keep other people from To
seeing what you entered on your SUBPOENA JUDICIALform, please press the Clear This Form button at the end of the form when finished.
: : : :
-against- NO.: FAX
ATTORNEY FOR STATE TAXPAYER/RESPONDENT: NAME OF COURT: STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE:
Defendant(s) BRANCH NAME: : . . . . . . . .(Name): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... APPLICATION OF
TAXPAYER/RESPONDENT
THE CLAIM OF OF THE STATE OF NEW YORK PEOPLE EXEMPTION AND FINANCIAL DECLARATION
NAME OF STATE TAX AGENCY:
CASE NUMBER:
TAX AGENCY NUMBER:
TO
(Copy the information required above from the Application for Earnings Withholding Order for Taxes (form WG-020). The top left space is for your or your attorney's name and address.)
GREETINGS: 1. I need the following earnings to support myself or my family (check and complete item a or b): each pay period. b. a. All earnings. $ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before me my attorney shown above at the address following (specify): , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned25 percent minimum withholding, I amas a witness in this action on to bepart of the my earnings during the date, to testify and give evidence willing for the following amount the withheld from 3. In addition to the
2. Please send all papers to withholding period: a. None b. Withhold: $ each pay period.
4. a. I am paid
daily weekly every is punishable as a contempt of court and will make you liable to twice a month monthly. Your failure to comply with this subpoena two weeks the gross pay whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a party on is: $ b. My per pay period. result of your failure to comply. c. My take-home pay is: $ per pay period. d. My payroll deductions are (item and amount):
Court in
Witness, Honorable County,
, one of the Justices of the , 20
day of
5. The following persons depend, in whole or in part, on me for support: Name a. b. Age Relationship to me Myself
(Attorney mustMonthly income and its source sign above and type name below)
Attorney(s) for
c. d. e. 6. The earnings of others listed in item 5 are now subject to wage assignments and Earnings Withholding Orders as follows (specify):
Office and P.O. Address
Form Adopted for Mandatory Use Judicial Council of California WG-026 [Rev. January 1, 2007]
Telephone No.: Facsimile No.: E-Mail Address: CLAIM OF EXEMPTION AND FINANCIALMobile Tel. No.: DECLARATION
(Wage Garnishment-State Tax Liability)
Page 1 of 2 Code of Civil Procedure, ยงยง 706.051, 706.076 www.courtinfo.ca.gov
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WG-026
APPLICATION OF (Name): CASE NUMBER:
TAXPAYER/RESPONDENT
7. My monthly expenses are as follows: a. Rent or house payment and maintenance . . . . . . . . . . . . . . . . . . $ b. Food and household supplies . . . . . . $ c. Utilities and telephone . . . . . . . . . . . $ d. Clothing . . . . . . . . . . . . . . . . . . . . . . $ e. Laundry and cleaning . . . . . . . . . . . $ f. Medical and dental payments . . . . . .$ g. Insurance (life, health, accident, etc.) . . . . . . . . . . . . . . . . . . $ h. School, child care . . . . . . . . . . . . . . . $ i. Child, spousal support (prior marriage) . . . . . . . . . . . . . . . . $ 8. List payments on installment and other debts. Creditor's name
j. Entertainment and incidentals . . . . k. Transportation and auto expenses (insurance, gas, repair) . . . . . . . . . . l. Installment payments (insert total and list below in item 8) . . . . . . m. Other (specify): . . . . . . . . . . . . . . . .
$ $ $ $
TOTAL MONTHLY EXPENSES (add a through m) . . . . . . . . . . . . . . . . $ Continued on Attachment 8. For Monthly payment Balance
9. What do you own? (State value.) a. Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b. Checking, savings and credit union accounts, etc. (list institutions): (1) $ (2) $ $ (3) $ (4) c. Cars, other vehicles, and boat equity (list make, year of each): (1) $ (2) $ $ (3) 10.
d. Real estate equity (addresses): . . $
e. Other personal property (jewelry, furniture, furs, stocks and bonds, etc. List separately):
Total for item e: . . . $
An Order Assigning Salary and Wages (for support) is now in effect as to my earnings. The amount payable under that order monthly. is: $ 11. Other facts that support this Claim of Exemption are (describe unusual medical needs, school tuition, expenses for recent family emergencies, or other unusual expenses to help the judge understand your budget): Continued on Attachment 11.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF TAXPAYER)
File this form with the clerk of the court and mail a copy to the tax agency as soon as possible. Keep a copy and take it with you to the court hearing. If you wish to obtain the advice of an attorney, you should do so at once.
WG-026 [Rev. January 1, 2007]
CLAIM OF EXEMPTION AND FINANCIAL DECLARATION
(Wage Garnishment-State Tax Liability)
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