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FINANCIAL INSTITUTION execunion STATE OF CONNECTICUT e Ua
PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT ee
WHO {S A NATURAL PERSON, www. jud.ct.gov
APRLICATION A ND EXECUTION (See page 2 for instructions to financial institution MEE SUe"
CGS. 3§ §2-356b, 52-367 and ADA Notice)
PA 44-7, 14-9
instructions - Judgment Creditor Or Attorney instructions - Gierk
4. Type or print iegibly. 4. Check the file to ensure that the information provided
2, Complete the application section; prepare original and 2 capies. on the application is correct. Va1714
3. Completa section 7 of the Exemption Claim Form, JO-CV-24a and attach to this form. 2. Sign original execution.
4. Present original and 1 copy to clerk of court Retain a copy. 3, Retum original to applicant, retain a copy for fle.
Address of court [_]. susicial district Geographic | Docket number
PO BOX 247 LITCHFIELD CT 067591 | Howsingsecsion [| number__- (CVI 460111995
Name and mailing address of Judgment Creditor or Attorney {To be completed by Judgment Creditor)
rLaw Offices 7
Howard Lee Schiff ,P.c.
P.G.Box 280245
E Hartford, CT 06128 9285 “ag
L a
Rame(e) and address(es} of Judgment Credlion(sy
CAPITAL ONE BANK USA, N.A.
RICHMOND, VA
ras
§ Name(s) and address(es) of Judgment Debtor(s)
Z GREGORY B ESKER, SR
8 (244 SMITH HILL RD WINSTED, CT 06098
‘B (Date ofjudgment 7. Amount of fudgenent (inoude, where applicabie, | 2. Amount of costs , Amount of judament, costs and fees (Add f and 2
| TATAS $8,111.67 reludarneny inorest and $390.16 $8,501.83
4-Total amount pald (any) ScTotal amiount unpaid (Subtract fom 3) | 6. Application tee for nancial malitullon 6xeuutlon (if not waived by the court)
$.00 $8,501.83 $100.00
(7. Application $668 paid tor prior @xecutions on this judgment | 6. Other court ordered postjudgment costs and fees BTola) of ems 5,6, 7 and &
$.00 $.00 $8,601.83
‘Chack F applicable ”
\s this judgment arising out of services rendered at a hospital? | Cc No. oO Yes oO postjudgment interest was ordered by the court
Hf this Is a judgment arising out of services rendered at a hospital, has a stay of a financial institution execution been or oy
entered pursuant to an installment payment order? ‘a ‘8S
fa stay of a financial institution execution tas bean entered, has the Judgment Debtor defaulted on an installment payment order?
No Yes (Spe
‘Signed (Jygament Creditar or Al . » Esq. Date signed ee we ) . 1
- FER1A 2018 60) S26~999
Financial itution Execution
To any proper officer,
Whereas on said Date of Judgment the above-named Judgrnent Creditor(s) recovered judgment against the above-named Judgment Debtor(s) before the above-
Named court for the amount of judgment, costs and fees stated above, as appears of record, whereof execution remains to be done.
These are, therefore, by authority of the state of Connecticut to command you:
Within seven days from your reosipt of this execution, make demand upon the main office of any financial institution having Its main office within your county, or if such
main office is not within your county and such financial institution has one or more branch offices within your county, upon an employee of such a branch affice, such
employee and such branch office having been designated by the financial institution in accordance with regulations adopted by the commissioner of Banking, for
Payment to you pursuant to section 52-367b(p) of the General Statutes of any nonexempt debt due said Judgment Debtor(s), which sum shall nat exceed the total
unpaid judgment, opsts and tees as stated above, plus postudgment interest as ordered by the court, applicable, plus the application fee and other court ordered
Postjudgment costs and fees and yout own fee. After having made such demand you ate directed to serve a true and attested copy of this execution, together with the
attached affidavit and exemption claim form, with your doings endorsed thereon, with the financial institution officer upon wham such demand was made. Said sum
shall be received by you and applied on this execution in accordance with the provisions of section 52-367b of the General Statuies. You shail not serve mare than one
financial institution execution per judgment debtor at a time, including capies thereof, Alter service of an execution on one For Count Use Only
financial institution, you shail not serve the same execution or a copy thereof upan another financial institution until receiving
confirmation from the preceding financial institution that the judgment debtor had insufficient funds at the preceding financial
institution available for collection fo satisty the execution, provided any such additional service is made not later than forty-five
days from the receipt by you of such execution. After service of an execution, you shall not serve the same execution or a
‘copy thersof upon such financial institution if an electronic direct deposit from a readily identifiable source described in
section 52 -376b (c) of the General Statutes was made to the judgment debtor's account within the look-back period,
described in section 52 -378b (c) of the General Statues (sixty days or, with regard to federal benefits, such greater period as
required by federat law). Hf no such deposit was made, you may subsequently serve the same execution or a copy thereof
upan such institution, provided the execution bas not expired or otherwise become unenforceable.
Hereof fail not, and make due return of thls writ with your doings thereon, according to law.
Signed (Assistant Clorky Date signed
Pi torz FINANCIAL INSTITUTION EXECUTION PROCEEDINGS
XB 2/08/16 see toe e yo
NOTE: The provisions of section 52-367b, as amended from time to time, take precedence over these instructions.
instructions To Financial Institution Upon Receipt Of A Financial institution Execution
When Judgment Debtor ts A Natural Person
. If any funds are removed from the judgment debtor's account pursuant to subsection {c) of section 52-3676 of the General Statutes,
complete section ft of the accompanying Exemption Claim Form (JD-CV-24a) and (1} send, forthwith, 2 copies of both this form and the
Exemption Ctaim Farm to the judgment debtor and to any secured party that is a party to a control agreement between you and such
secured party under article 9 of title 42a of the General Statutes, postage pre-paid, at the last known address of the judgment debtor and
of any such secured party with respect fo the. affected accounts an the records of your institution and (2) mai) notice to the judgment
debtor as required by 31CFR212.6 and 212.7.
2. Remove from the judgment debtor's account the amount of any debts due from you to the judgment debtor not exceeding the Total
Amount Unpaid as appears on page 1 of this form plus interest and the Application ‘Fee for Financial Institution Execution and other court
ordered postjudgment costs or fees and the serving officer's fee, before your midnight deadline, as defined in’ section 42a-4-104 of the
General Statutes. If an electronic direct deposit is readily identifiable as exempt federal veterans’ benefits, Social Security benefits,
including, but not limited to, retirement, survivors' and disability benefits, supplemental security income benefits, exempt benefits paid by
the federai Railroad Retirement Board or the federal Office of Personnel Management, unemployment compensation benefits exernpt
under section 52-352b of the Connecticut General Statutes, of child support payments processed and received pursuant to Title 'V-D of
the Sociaf Security Act were made to the judgment debtor's account during the iook-back period of,either diye, sixtyday period preceding
the date that the execution was setved on you, or, with regard to federal benefits, such greater period as required by federal law then you
shall leave the lesser of the account balance or one thousand dollars in the judgment debtor's account, ‘provided nothing in this
subsection shall be construed to limit your right or obligation to remove such funds from the judg nent debtor's account if required by any
other provision of law or by a court order. The judgment debtor shalt have full and customary accéss fo such funds teft tri tHe judgment
debtor's account. You may notify the judgment creditor that funds have been jeft in the judgijent debtor's accSunt pursuant to this
provision. Nothing herein shail alter the exempt status of funds which are exempt from execution under subsection (a) of section 52-3675
of the General Statutes or undet any other provision-of state or federat law, or the right of a judgment debtor to claifn such exemption.
Nothing herein shall be construed to affect any other rights or obligations of the financial institution with regard to the funds in the
judgment debtor's account, +,
3. You must hald the amount removed from the judgrnent debtor's account pursuant to this execution for fifteen days from the date you mail
the copies of this form and the Exemption Ciaim Form to the judgment debtor and any secured party. During such fifteen day period you
must not pay the officer serving this execution.
4, If the judgment debtor retums the Exemption Claim Form or other written notice that an exemption is being claimed, and if any secured
party delivers to you written notice of such secured party's claim of a prior perfected security interest in such deposit account, you must,
within two business days of receipt of such notice, send a copy of such notice to the clerk of the court which issued the execution. You
must continue to hold the amount removed from the judgment debtor's account for forty-five days or until a court order is received
regarding disposition of the funds, whichever occurs earlier. If no order is received within forty-five days of the date you send a copy of
the Exemption Claim Form or notice of exemption or a secured party claim notice to the clerk of the court, you must return the funds fo
the judgment debtor's account.
if you do not receive a claint of exemption of secured party Giri notice within fifteen days of the mailing to the judgment debtor and any
secured party of the execution and Exemption Clair Form you must, upon demand, forthwith pay the serving officer the amount
remaved from the judgment debtor's account.
6. if no exemption claim or secured party claim notice is filed or if the court orders you to pay the serving officer an amount removed from
the judgment debtor's account not exceeding the amount due on the execution ard you fail or refuse to do so, you shail be liable in an
action therefor to the judgement creditor(s} named in the execution for the amount of nonexempt monies which you fail or refuse to pay
over, If no exemption claim is filed or if the court orders you to pay the serving officer an amount removed from the judgment debtor's
account not exceeding the amount due on the execution and you fail or refuse to do so, you shail be fiable in an action therefor to the
judgment creditor(s} name in the execution for the amount of nonexempt monies which you fail or refuse ta pay over, excluding funds of
up ta one thousand datiars which you in good faith allowed the judgment debtor to access pursuant to subsection (c) of section 52-3676
of the General Statutes.
7. if you pay exempt monies from the account of the judgment debtor contrary to these instructions, or the provisions of section 52-367b of
the General Statutes, you shail be liable in an action therefor to the judgment debtor for any exempt monies so paid. If you pay exernpt
monies from the accaunt of the judgment debtor contrary to these instructions, or the provisions of section 52-367b of the General
Statutes, you shall be tiable in an action therefor to the judgment debtor for any exempt monies so paid and you shall refund ar waive
any charges of fees by you, including, but not fimited to, dishonored check fees, overdraft fees or minimum balance service charges and
legal process fees, which were assessed as a resuit of such payment of exempt monies.
a
ADA NOTICE .
‘The Judicial Branch of the State of Gonnecticut complies with the Americans wit
‘Disabilities Act (ADA). if you need a reasonable accommodation in accordangs with the
ADA, contact a court clerk of an ADA contact person listed at vww.jud.ct. goW/ADA.
JD-GV-24 (back/page 2) Rev. 2-15 Page 2 of 2EXEMPTION CLAIM FORM
FINANCIAL INSTITUTION EXECUTION ST eee ew ony
ID-CV-24A_Rev. 2-15
C.G.S, 31-5B(i), 52-321a, 52-360a, §2-352b, 52-361a, SEE INSTRUCTIONS ON BACK/PAGE 2 www. jud.ct.gov =e
§2-367b, 29 U.S.C. 206(a)(1)
Name and address of Judgment Debtor or Attomey
{To be completed by judgment creditor or attomey)
To & 7
GREGORY & ESKER, SR CN YLI71i i ana
214 SMITH HILL RD
THIS COMMUNTCATION IS
L WINSTED, CT 046098 4 FROM & DEBT COLLECTOR
Section 1 — (To be completed by judgment creditor}
Judicl 5 Geographical | Name and addreas of Court (Number, Steel, Town and Zip Cade)
ial Housing Area
District Li session [] Number FO BOX 247 LITCHFYIELD CT 06759
Nam of case Name of Judgment Debtor Docket number
CAPITAL ONE BANK USA, Nad.) GREGORY & ESKER, SR CV1460111999S
vs GREGORY B ESKER, SH
Section 2 — (To be completed by financial institution - see instructions on back/page 2)
Name and address of financial institution to which exemption claim (any) s to be retumed Date of mailing to Judgment Debtor
Last 4 Digits of the Account Number(s) “Amount removed pursuant to execution ‘Amount and type of readily identifiable exempt funds not removed
(_] Additional sheet(s) attached hereto and made a part hereof (if necessary).
Section 3 — Notice To Judgment Debtor
AS a resuit of a judgment entered against you, the attached execution has been issued against funds deposited by you in the
financial institution named above. In compliance with this execution, the financial institution has removed the amount of money indicated
above from the account(s) enumerated above.
THE MONEY IN YOUR ACCOUNT(S) MAY BE EXEMPT FROM EXECUTION - The money in your account(s) may be protected from
execution by state statutes or by other laws or regulations of this state or of the United States. A checklist and a description of the mast
common exemptions established by law are set forth below.
HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW. If you wish to claim that the money in your account(s) is exempt by law
from execution, you must fill out and sign before a proper official the Affidavit of Claim of Exemption below and mail or deliver this
exemption claim form to the financial institution at the above address. This form must be received by the financial institution no later than
15 days from the DATE OF MAILING TO THE JUDGMENT DEBTOR indicated above.
Upon receipt of this form the financial institution will forward it to the Superior Court and the court clerk wil notify you and the judgment
creditor of the date on which a hearing will be held by the court to determine the issues raised by your claim.
SECTION 4 — AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW
|, the judgment debtor named above, claim and certify under the penalty of false statement that the money in the above account
is exempt by law from execution as follows: (°X” aif that apply to the funds contained in this account)
C Social Security benefits (section 52-352b(g)) LZ Private pension, trust, retirement, or medical savings
[_] Unemployment benefits (section 52-352b(g)) account payments (sections §2-321a, 52-352b(m))
[_] Worker's Compensation benefits (section 52-362b(g)) (1 Health or disability insurance payments (section 52-352b(e)}
(_] Veteran's benefits (section 52-352b(g)) [_] An amount in the bank not to exceed $1000 (section 52-352b(r))
L_] Public Assistance payments (section 52-352b(d)) LL] Other claim of exempt funds (Explain basis for claim of exemption):
LJ Wages* (section 52-3614)
(_] Wages eamed by a public assistance recipient under an
incentive earnings or similar program {section 52-352b(d)) Amount claimed to be exempt
[_] Court-ordered child support payments (section 52-352b(h)) if less than the entire amount:
{_] Alimony and support other than child support" (section 52-352b(n))
*See Note Regarding Exemption for Wages and Alimony on back/page 2.
Signed Date signed Telephone number
‘Compiete mailing address of Judgment Debtor
Subscribed and sworn Date At (Town) Signed (Notary Public, Commissioner of Superior Court)
to before me on :
Page t of 2Instructions
To Financial Institution
1. Complete section 2 of this form and (1} send 2 copies
of this form and the financial institution execution form
ta the udgment debtor and ta any Secured party that
is party to a control agreement between the financial
institution and such secured party under article 9 of
title 42a pursuant to section 52-367b of the General
Statutes and (2) mail notice to judgment debtor as
required by 31CFR212.6 and 212.7.
N
. If this claim of exemption is returned completed, fill out
section 4 of this form and mail, within two business
days, fo the issuing clerk's office at the address of
court indicated on the front side. See additional
instructions on the financial institution execution form,
To Clerk
requesting the execution.
3. If judgment debtor completes and returns this form claiming an
exemption, enter the appearance of the judgment debtor with address
set forth on page 1.
Complete section 7 below.
OaE
creditor.
Set matter down for short calendar hearing.
. Attach this form to each financial institution execution issued in a civil
family matter against a judgment debtor that is a natural person.
2. Deliver the execution along with this forrn to the judgment creditor
. Send file-stamped copy of this form to judgment debtor and judgment
or
7. After hearing, send copy of any order entered to the financial institution.
Note Regarding Exemption For Wages And Alimony
The amount of wages and alimony that may be subject to levy or other withholding for payment of a judgment is the lesser of (1) twenty-
five per cent of the individual's disposable eamings for that week, or (2) the amount by which the individual's disposable earnings for that
week exceed forty times the higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair Labor Standards Act of 1938,
U.S.C. fit. 29, Section 206(a){1), or (B), the state minimum hourly wage under subsection (i) of Section 31-58, in effect at the time the
earnings are payable.
Section 52-360a(4} of the Connecticut General Statutes defines "disposable earnings" as that part of the earnings of an individual
remaining after the deduction from those eamings 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,
Section 5 — Proper Officer Must Complete This Section
Name and titles of proper officer
Date of service on financial institution
| Telephone number
Section 6 — (To be completed by financial institution upon return of exemption claim form)
Date claim received Date mailed fo court Name of financial institution
| Telephone number
Section 7 — Notice To Judgment Debtor And Judgment Creditor
The assets in dispute are being held for (1) forty-five days from the date the exemption claim form was received by the financial
institution designated on the front of this form or (2) until disposition is ordered by the court at a hearing to be held at short
calendar on the date set forth below, whichever occurs earlier.
Date of hearing Time of hearing [Tam [courtroom
Cl pm.
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.ctgowADA,
Signed (Assistant Clerk)
Bate signed
Order
The CourtMagistrate, having held a hearing to determine the issues raised by this claim, hereby orders that:
By ihe Court (Name of Judge/Famiy Support Magistrate Magistrate)
[7] Judge (] Fsm
[J Magistrate
Signed (Judge/Family Support Magistrale/Magistrata/Assistant Clerk}
Baie signed
|
JD-CV-24A (page 2) Rev. 2-15
Page 2 of 2
Preview
FINANCIAL INSTITUTION execunion STATE OF CONNECTICUT e Ua PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT ee WHO {S A NATURAL PERSON, www. jud.ct.gov APRLICATION A ND EXECUTION (See page 2 for instructions to financial institution MEE SUe" CGS. 3§ §2-356b, 52-367 and ADA Notice) PA 44-7, 14-9 instructions - Judgment Creditor Or Attorney instructions - Gierk 4. Type or print iegibly. 4. Check the file to ensure that the information provided 2, Complete the application section; prepare original and 2 capies. on the application is correct. Va1714 3. Completa section 7 of the Exemption Claim Form, JO-CV-24a and attach to this form. 2. Sign original execution. 4. Present original and 1 copy to clerk of court Retain a copy. 3, Retum original to applicant, retain a copy for fle. Address of court [_]. susicial district Geographic | Docket number PO BOX 247 LITCHFIELD CT 067591 | Howsingsecsion [| number__- (CVI 460111995 Name and mailing address of Judgment Creditor or Attorney {To be completed by Judgment Creditor) rLaw Offices 7 Howard Lee Schiff ,P.c. P.G.Box 280245 E Hartford, CT 06128 9285 “ag L a Rame(e) and address(es} of Judgment Credlion(sy CAPITAL ONE BANK USA, N.A. RICHMOND, VA ras § Name(s) and address(es) of Judgment Debtor(s) Z GREGORY B ESKER, SR 8 (244 SMITH HILL RD WINSTED, CT 06098 ‘B (Date ofjudgment 7. Amount of fudgenent (inoude, where applicabie, | 2. Amount of costs , Amount of judament, costs and fees (Add f and 2 | TATAS $8,111.67 reludarneny inorest and $390.16 $8,501.83 4-Total amount pald (any) ScTotal amiount unpaid (Subtract fom 3) | 6. Application tee for nancial malitullon 6xeuutlon (if not waived by the court) $.00 $8,501.83 $100.00 (7. Application $668 paid tor prior @xecutions on this judgment | 6. Other court ordered postjudgment costs and fees BTola) of ems 5,6, 7 and & $.00 $.00 $8,601.83 ‘Chack F applicable ” \s this judgment arising out of services rendered at a hospital? | Cc No. oO Yes oO postjudgment interest was ordered by the court Hf this Is a judgment arising out of services rendered at a hospital, has a stay of a financial institution execution been or oy entered pursuant to an installment payment order? ‘a ‘8S fa stay of a financial institution execution tas bean entered, has the Judgment Debtor defaulted on an installment payment order? No Yes (Spe ‘Signed (Jygament Creditar or Al . » Esq. Date signed ee we ) . 1 - FER1A 2018 60) S26~999 Financial itution Execution To any proper officer, Whereas on said Date of Judgment the above-named Judgrnent Creditor(s) recovered judgment against the above-named Judgment Debtor(s) before the above- Named court for the amount of judgment, costs and fees stated above, as appears of record, whereof execution remains to be done. These are, therefore, by authority of the state of Connecticut to command you: Within seven days from your reosipt of this execution, make demand upon the main office of any financial institution having Its main office within your county, or if such main office is not within your county and such financial institution has one or more branch offices within your county, upon an employee of such a branch affice, such employee and such branch office having been designated by the financial institution in accordance with regulations adopted by the commissioner of Banking, for Payment to you pursuant to section 52-367b(p) of the General Statutes of any nonexempt debt due said Judgment Debtor(s), which sum shall nat exceed the total unpaid judgment, opsts and tees as stated above, plus postudgment interest as ordered by the court, applicable, plus the application fee and other court ordered Postjudgment costs and fees and yout own fee. After having made such demand you ate directed to serve a true and attested copy of this execution, together with the attached affidavit and exemption claim form, with your doings endorsed thereon, with the financial institution officer upon wham such demand was made. Said sum shall be received by you and applied on this execution in accordance with the provisions of section 52-367b of the General Statuies. You shail not serve mare than one financial institution execution per judgment debtor at a time, including capies thereof, Alter service of an execution on one For Count Use Only financial institution, you shail not serve the same execution or a copy thereof upan another financial institution until receiving confirmation from the preceding financial institution that the judgment debtor had insufficient funds at the preceding financial institution available for collection fo satisty the execution, provided any such additional service is made not later than forty-five days from the receipt by you of such execution. After service of an execution, you shall not serve the same execution or a ‘copy thersof upon such financial institution if an electronic direct deposit from a readily identifiable source described in section 52 -376b (c) of the General Statutes was made to the judgment debtor's account within the look-back period, described in section 52 -378b (c) of the General Statues (sixty days or, with regard to federal benefits, such greater period as required by federat law). Hf no such deposit was made, you may subsequently serve the same execution or a copy thereof upan such institution, provided the execution bas not expired or otherwise become unenforceable. Hereof fail not, and make due return of thls writ with your doings thereon, according to law. Signed (Assistant Clorky Date signed Pi torz FINANCIAL INSTITUTION EXECUTION PROCEEDINGS XB 2/08/16 see toe e yo NOTE: The provisions of section 52-367b, as amended from time to time, take precedence over these instructions. instructions To Financial Institution Upon Receipt Of A Financial institution Execution When Judgment Debtor ts A Natural Person . If any funds are removed from the judgment debtor's account pursuant to subsection {c) of section 52-3676 of the General Statutes, complete section ft of the accompanying Exemption Claim Form (JD-CV-24a) and (1} send, forthwith, 2 copies of both this form and the Exemption Ctaim Farm to the judgment debtor and to any secured party that is a party to a control agreement between you and such secured party under article 9 of title 42a of the General Statutes, postage pre-paid, at the last known address of the judgment debtor and of any such secured party with respect fo the. affected accounts an the records of your institution and (2) mai) notice to the judgment debtor as required by 31CFR212.6 and 212.7. 2. Remove from the judgment debtor's account the amount of any debts due from you to the judgment debtor not exceeding the Total Amount Unpaid as appears on page 1 of this form plus interest and the Application ‘Fee for Financial Institution Execution and other court ordered postjudgment costs or fees and the serving officer's fee, before your midnight deadline, as defined in’ section 42a-4-104 of the General Statutes. If an electronic direct deposit is readily identifiable as exempt federal veterans’ benefits, Social Security benefits, including, but not limited to, retirement, survivors' and disability benefits, supplemental security income benefits, exempt benefits paid by the federai Railroad Retirement Board or the federal Office of Personnel Management, unemployment compensation benefits exernpt under section 52-352b of the Connecticut General Statutes, of child support payments processed and received pursuant to Title 'V-D of the Sociaf Security Act were made to the judgment debtor's account during the iook-back period of,either diye, sixtyday period preceding the date that the execution was setved on you, or, with regard to federal benefits, such greater period as required by federal law then you shall leave the lesser of the account balance or one thousand dollars in the judgment debtor's account, ‘provided nothing in this subsection shall be construed to limit your right or obligation to remove such funds from the judg nent debtor's account if required by any other provision of law or by a court order. The judgment debtor shalt have full and customary accéss fo such funds teft tri tHe judgment debtor's account. You may notify the judgment creditor that funds have been jeft in the judgijent debtor's accSunt pursuant to this provision. Nothing herein shail alter the exempt status of funds which are exempt from execution under subsection (a) of section 52-3675 of the General Statutes or undet any other provision-of state or federat law, or the right of a judgment debtor to claifn such exemption. Nothing herein shall be construed to affect any other rights or obligations of the financial institution with regard to the funds in the judgment debtor's account, +, 3. You must hald the amount removed from the judgrnent debtor's account pursuant to this execution for fifteen days from the date you mail the copies of this form and the Exemption Ciaim Form to the judgment debtor and any secured party. During such fifteen day period you must not pay the officer serving this execution. 4, If the judgment debtor retums the Exemption Claim Form or other written notice that an exemption is being claimed, and if any secured party delivers to you written notice of such secured party's claim of a prior perfected security interest in such deposit account, you must, within two business days of receipt of such notice, send a copy of such notice to the clerk of the court which issued the execution. You must continue to hold the amount removed from the judgment debtor's account for forty-five days or until a court order is received regarding disposition of the funds, whichever occurs earlier. If no order is received within forty-five days of the date you send a copy of the Exemption Claim Form or notice of exemption or a secured party claim notice to the clerk of the court, you must return the funds fo the judgment debtor's account. if you do not receive a claint of exemption of secured party Giri notice within fifteen days of the mailing to the judgment debtor and any secured party of the execution and Exemption Clair Form you must, upon demand, forthwith pay the serving officer the amount remaved from the judgment debtor's account. 6. if no exemption claim or secured party claim notice is filed or if the court orders you to pay the serving officer an amount removed from the judgment debtor's account not exceeding the amount due on the execution ard you fail or refuse to do so, you shail be liable in an action therefor to the judgement creditor(s} named in the execution for the amount of nonexempt monies which you fail or refuse to pay over, If no exemption claim is filed or if the court orders you to pay the serving officer an amount removed from the judgment debtor's account not exceeding the amount due on the execution and you fail or refuse to do so, you shail be fiable in an action therefor to the judgment creditor(s} name in the execution for the amount of nonexempt monies which you fail or refuse ta pay over, excluding funds of up ta one thousand datiars which you in good faith allowed the judgment debtor to access pursuant to subsection (c) of section 52-3676 of the General Statutes. 7. if you pay exempt monies from the account of the judgment debtor contrary to these instructions, or the provisions of section 52-367b of the General Statutes, you shail be liable in an action therefor to the judgment debtor for any exempt monies so paid. If you pay exernpt monies from the accaunt of the judgment debtor contrary to these instructions, or the provisions of section 52-367b of the General Statutes, you shall be tiable in an action therefor to the judgment debtor for any exempt monies so paid and you shall refund ar waive any charges of fees by you, including, but not fimited to, dishonored check fees, overdraft fees or minimum balance service charges and legal process fees, which were assessed as a resuit of such payment of exempt monies. a ADA NOTICE . ‘The Judicial Branch of the State of Gonnecticut complies with the Americans wit ‘Disabilities Act (ADA). if you need a reasonable accommodation in accordangs with the ADA, contact a court clerk of an ADA contact person listed at vww.jud.ct. goW/ADA. JD-GV-24 (back/page 2) Rev. 2-15 Page 2 of 2EXEMPTION CLAIM FORM FINANCIAL INSTITUTION EXECUTION ST eee ew ony ID-CV-24A_Rev. 2-15 C.G.S, 31-5B(i), 52-321a, 52-360a, §2-352b, 52-361a, SEE INSTRUCTIONS ON BACK/PAGE 2 www. jud.ct.gov =e §2-367b, 29 U.S.C. 206(a)(1) Name and address of Judgment Debtor or Attomey {To be completed by judgment creditor or attomey) To & 7 GREGORY & ESKER, SR CN YLI71i i ana 214 SMITH HILL RD THIS COMMUNTCATION IS L WINSTED, CT 046098 4 FROM & DEBT COLLECTOR Section 1 — (To be completed by judgment creditor} Judicl 5 Geographical | Name and addreas of Court (Number, Steel, Town and Zip Cade) ial Housing Area District Li session [] Number FO BOX 247 LITCHFYIELD CT 06759 Nam of case Name of Judgment Debtor Docket number CAPITAL ONE BANK USA, Nad.) GREGORY & ESKER, SR CV1460111999S vs GREGORY B ESKER, SH Section 2 — (To be completed by financial institution - see instructions on back/page 2) Name and address of financial institution to which exemption claim (any) s to be retumed Date of mailing to Judgment Debtor Last 4 Digits of the Account Number(s) “Amount removed pursuant to execution ‘Amount and type of readily identifiable exempt funds not removed (_] Additional sheet(s) attached hereto and made a part hereof (if necessary). Section 3 — Notice To Judgment Debtor AS a resuit of a judgment entered against you, the attached execution has been issued against funds deposited by you in the financial institution named above. In compliance with this execution, the financial institution has removed the amount of money indicated above from the account(s) enumerated above. THE MONEY IN YOUR ACCOUNT(S) MAY BE EXEMPT FROM EXECUTION - The money in your account(s) may be protected from execution by state statutes or by other laws or regulations of this state or of the United States. A checklist and a description of the mast common exemptions established by law are set forth below. HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW. If you wish to claim that the money in your account(s) is exempt by law from execution, you must fill out and sign before a proper official the Affidavit of Claim of Exemption below and mail or deliver this exemption claim form to the financial institution at the above address. This form must be received by the financial institution no later than 15 days from the DATE OF MAILING TO THE JUDGMENT DEBTOR indicated above. Upon receipt of this form the financial institution will forward it to the Superior Court and the court clerk wil notify you and the judgment creditor of the date on which a hearing will be held by the court to determine the issues raised by your claim. SECTION 4 — AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW |, the judgment debtor named above, claim and certify under the penalty of false statement that the money in the above account is exempt by law from execution as follows: (°X” aif that apply to the funds contained in this account) C Social Security benefits (section 52-352b(g)) LZ Private pension, trust, retirement, or medical savings [_] Unemployment benefits (section 52-352b(g)) account payments (sections §2-321a, 52-352b(m)) [_] Worker's Compensation benefits (section 52-362b(g)) (1 Health or disability insurance payments (section 52-352b(e)} (_] Veteran's benefits (section 52-352b(g)) [_] An amount in the bank not to exceed $1000 (section 52-352b(r)) L_] Public Assistance payments (section 52-352b(d)) LL] Other claim of exempt funds (Explain basis for claim of exemption): LJ Wages* (section 52-3614) (_] Wages eamed by a public assistance recipient under an incentive earnings or similar program {section 52-352b(d)) Amount claimed to be exempt [_] Court-ordered child support payments (section 52-352b(h)) if less than the entire amount: {_] Alimony and support other than child support" (section 52-352b(n)) *See Note Regarding Exemption for Wages and Alimony on back/page 2. Signed Date signed Telephone number ‘Compiete mailing address of Judgment Debtor Subscribed and sworn Date At (Town) Signed (Notary Public, Commissioner of Superior Court) to before me on : Page t of 2Instructions To Financial Institution 1. Complete section 2 of this form and (1} send 2 copies of this form and the financial institution execution form ta the udgment debtor and ta any Secured party that is party to a control agreement between the financial institution and such secured party under article 9 of title 42a pursuant to section 52-367b of the General Statutes and (2) mail notice to judgment debtor as required by 31CFR212.6 and 212.7. N . If this claim of exemption is returned completed, fill out section 4 of this form and mail, within two business days, fo the issuing clerk's office at the address of court indicated on the front side. See additional instructions on the financial institution execution form, To Clerk requesting the execution. 3. If judgment debtor completes and returns this form claiming an exemption, enter the appearance of the judgment debtor with address set forth on page 1. Complete section 7 below. OaE creditor. Set matter down for short calendar hearing. . Attach this form to each financial institution execution issued in a civil family matter against a judgment debtor that is a natural person. 2. Deliver the execution along with this forrn to the judgment creditor . Send file-stamped copy of this form to judgment debtor and judgment or 7. After hearing, send copy of any order entered to the financial institution. Note Regarding Exemption For Wages And Alimony The amount of wages and alimony that may be subject to levy or other withholding for payment of a judgment is the lesser of (1) twenty- five per cent of the individual's disposable eamings for that week, or (2) the amount by which the individual's disposable earnings for that week exceed forty times the higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair Labor Standards Act of 1938, U.S.C. fit. 29, Section 206(a){1), or (B), the state minimum hourly wage under subsection (i) of Section 31-58, in effect at the time the earnings are payable. Section 52-360a(4} of the Connecticut General Statutes defines "disposable earnings" as that part of the earnings of an individual remaining after the deduction from those eamings 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, Section 5 — Proper Officer Must Complete This Section Name and titles of proper officer Date of service on financial institution | Telephone number Section 6 — (To be completed by financial institution upon return of exemption claim form) Date claim received Date mailed fo court Name of financial institution | Telephone number Section 7 — Notice To Judgment Debtor And Judgment Creditor The assets in dispute are being held for (1) forty-five days from the date the exemption claim form was received by the financial institution designated on the front of this form or (2) until disposition is ordered by the court at a hearing to be held at short calendar on the date set forth below, whichever occurs earlier. Date of hearing Time of hearing [Tam [courtroom Cl pm. 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.ctgowADA, Signed (Assistant Clerk) Bate signed Order The CourtMagistrate, having held a hearing to determine the issues raised by this claim, hereby orders that: By ihe Court (Name of Judge/Famiy Support Magistrate Magistrate) [7] Judge (] Fsm [J Magistrate Signed (Judge/Family Support Magistrale/Magistrata/Assistant Clerk} Baie signed | JD-CV-24A (page 2) Rev. 2-15 Page 2 of 2