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FINANCIAL INSTITUTION EXECUTION ” STATE OF CONNECTICUT (Ae TE i
PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT APEEABA®
WHO IS A NATURAL PERSON, www.jud.ct.gov
APPLICATION AND EXI . . o .
JD-CV-24 Rev. 245 ECUTION (See page 2 for instructions to financial institution ION ltl HA
C.G.S. §§ 52-3660, 52-3675 and ADA Notice) Exissu
PA.147, 149
Instructions - Judgment Creditor Or Attorney Instructions - Clerk
1. Type or print legibly. 1. Check the file to ensure thal the information provided
2. Compiete the application section; prepare original and 2 copies. on the application is corect.
3, Complete section 1 of the Exemption Claim Form, JO-CV-24a and altach to this form. 2. Sign original execution.
4. Prosent original and 1 copy to clerk of court, Retain a copy. _-3. Return original to applicant, retain a copy for file.
‘Address af court, P<] Judicial aistrict i Dockel number —
Bridgeport Judicial District 1061 Main Street Bridgeport, CT 0660477 Housing session al FBTCV176061471
Name and malling address of Judgment Creditor or Altorney (To be completed by Judgment Creditor)
T 7
Discover Bank
c/o SCHREIBER/COHEN, LLC
53 Stiles Road, Suite,A102
Salem, NH 03079
L I
Name(s) and address(es) of udgment creditors)
Discover Bank
C/O Discover Products inc 6500 New Albany Road East
New Albany. OH 43054
Name(s) and address(es) of dudgment Debtor(s)
MICHAEL PATRICK s ©)
339 MOOSE HILL RD
MONROE, CT 06468-2412
Dale of judginent
04/27/17
4. Total amount pad {f any)
$0.00
‘Application fees pald for prior executions on this Judgment
3968025
Feld]
3. Amount of judgment, costs and fees (Add T and a)
9569.68
- Applation fee for inancianinstilulion execution {ifhat walved by the cout
$105
%. Other count ordered postjudgment costs and fees >
Application
ToT tens.
$0.00 $0.00 $9674.68
‘Check if applicable ‘2!
Ts this judgment arising out of services rendered at ahosphtal? @, [X]No [_] Yes postjudgment interest was ordered:by the court
Ifthis is a judgment arising out of services rendered at a hospilal, has a stay of a financial institution execution been D Ne oD Ye
entered pursuant lo an installment payment order? ° es
Ifa stay of a financial institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? 7
Yes (Specify): Defendant defaulted on payment.
ey) Dale signed Telephone number ———
: gis l(7 1-800-423-8142
Finangiatinstitution Execution
Toal roper officer,
Whereas on said Date of Judgment the above-named Judgment 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 receipt 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 office, 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(b) of the General Statutes of any nonexempt debt due said Judgment Debtor(s), which sum shall not exceed the total
Unpaid judgment, costs and fees as stated above, plus postiudgment interest as ordered by the court, if applicable, plus the application fee and other court ordered
postjudgment costs and fees and your own fee. After having made such demand you are 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 whom 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 Statutes. You shall not serve more than one
financial institution execution per judgment debtor at a time, including copies thereof, After service of an execution on one For Court Use Only
financial institution, you shall not serve the same execution or a copy thereof upon 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 to satisfy 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 thereof 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 -376b (c) of the General Statues (sixty days or, with regard to federal benefits, such greater period as
required by federal law). Ifno such deposit was mage, you may subsequently serve the same execution or a copy thereof
upon such institution, provided the execution has np expired, or otherwise become unenforceable.
Hereof fail not, and make dugretu ith your doings thereon, according tp law.
Signed (Assistant Clerk) Date sired
Rel (7
Pane 4 af? FINANCIAL INSTITUTION EXECUTION PROCEEDINGSNOTE: 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 Is A Natural Person
. If any funds are removed from the judgment debtor's account pursuant to subsection (c) of section 52-367b of the General Statutes,
complete section II of the accompanying Exemption Claim Form (JD-C\V-24a) and (1) send, forthwith, 2 copies of both this form-and the
Exemption Claim Form 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 ahy such secured party with respect to the affected accounts on the records of your institution and (2) mail notice to the judgment
debtor as required by 31CFR212.6 and 212.7.
N
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 federal Railroad Retirement Board or the federal Office of Personnel Management, unemployment compensation benefits exempt
under'section 52-352b of the Connecticut General Statutes, or child support payments processed and received pursuant to Title. IV-D of
the Social ‘Security Act were made to the judgment debtor's account during the look-back period of either the sixty-day period preceding
the date that thé execution was served on you, or, with regard to féderal 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 judgment:debtor's account if required by any
other provision of law or by a court order. The judgment debtor shall have full and customary access’ to’ such funds left in the judgment
debtor's account. You .may notify the judgment creditor that funds have been left in the judgment ‘debtor's account pursuant to this
provision. Nothing herein shall alter the exempt status of funds which are exenipt from execution under subsection (a) of section §2-367b
of the General Statutes. or under any other provision of state or federal law, or the right of'a-judgment.debtor to claim 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 hold the amount removed from the judgment debtor's account pursuant to this execution for fifteen days from the date you mail
the copies of this form and the Exemption Claim 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 returns 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 ofder 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 to
the judgment debtor’s account.
5: If you do not receive a claim of exemption or secured party claim-notice within fifteen days of the mailing to the judgment debtor and any
secured party of the execution and Exemption Claim Form you: must, upon demand, forthwith pay the serving officer the amount
removed from the judgment debtor's account.
a
. 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 and you fail or refuse to do so, you shall 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 shall be liable in an action therefor to the
judgment creditor(s) name in the execution for the amount of nonexempt monies which you fail or refuse to pay over, excluding funds of
up to one thousand dollars which you in good faith allowed the judgment debtor to access pursuant to subsection (c) of section 52-367b
of the General Statutes.
nN“
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 shall be liable in an action therefor to the judgment debtor for any exempt monies so paid. 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 shall be liable in an action therefor to the judgment debtor for any exempt monies so. paid and you shall refund or waive
any charges of fees by you, including, but not limited to, dishonored check fees, overdraft fees or minimum balance service charges and
legal process fees, which were assessed as a result of such payment of exempt monies.
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 al wivv.jud.ct.gov/ADA.
JD-CV-24 (baci/page 2) Rev, 2-15 Page 2 of 2EXEMPTION CLAIM FORM
FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTIOUT 48 3
ge ia yeaa 2-3805, 629820, £2-3615, SEE INSTRUCTIONS ON BACHPAGE 2 weve jud.et.gov msi
£2. SO6IaN1p
Name sng agdrese of cuegmeni Debtor or Aatomey
{To oe completzd oy josgment creator ar sttomey)
For court ose cay
MXHIPEX
iH
OT 1
To: MICHAEL J PATRICK
339 MOOSE HILL RD
MONROE, CT 06468-2412
L J
Section 1 — (To be completed by judyment creditor)
Tseagraphical Nama anid sddress of Coun (MLAMDEr, ON
. 4, Town and zie Cove}
Judicial Hi = 3 * * ’
xX fuaicial Session a HES cer Bridzenort Judicial District 1061 Main Street Bridzenort. CT 06604
ame of aac Name of Juagmen: Oealor Docket number
Discover Bank v, MICHAEL J PATRICK MICHAEL J PATRICK FBTCV176061471
Section 2— {To be completed by financial institution - see instructions on back/paye 2)
Name and address of inancial insiuvon te wtih exempron-cialm ji ay) Is fo GS reamed Date of malting to Jaen Deer
Taste Dagiie of the Account Murnoens)
shest|s)
Section 3 3—Notice To Judgment Debtor
As a result of a judgment entered against you, the attached execution has. been issued agsinst funds deposited by you inthe
financial institution named above. To camply with this execution, the financial instiution has-removed the amount of money indicated
above from the account/s] listed above.
THE MONEY IN YOUR ACCOUNT(S) MAY BE EXEMPT FROM EX! i
execution by state statutes or by other laws or regulations of Connecticut or of the United States. A checklist amd a description of che most
common exemptions established by Isa are set forth below,
HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW. léyou wish fo claim thatthe monay in your account(s} is exempt by law
from axgoution, you ntust fill out and sign before 3 proper official the Affidavit of Claim of Exemption below and mail or deliver this
exemption elsin: form to the financial institution st the shove address. This form must be recsived by the financial. institution mo jater than
15 days from the DATE OF MAILING TC THE JUOGMENT DEBTOR indicated above.
Upon reesipt cf this form the financial it vill send it te the Superior Court and the cour clerk will notify you and the judgment
eraditor of the date on which 3 = hesring will be held by the court to determina the issues raised by your claim.
SECTION 4 — AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW
I, 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: ("%" ail that eopsy fo the funds contained in this account)
and
[7] Seis! Security benefits (section $2-262bigi |] Private pension, trust, retirement, or madical sa
[_] Unemployment benefits ( socount payments [sections $2-321a, 62-3 3
oO Workers Compensation benaiits (5 oO Heskh or disability msuranse psynrents {section 52-352b{2))
[_] Veteran's benefits (seotion €2-252bi0)) [J An smauni in the bank not to axo22d $1000 (section §2-242b(1})
[] Fublic Assistance payments (section 52-362b(d 1} oO Other slain of exempt funds jExpian oasis for clin sf exemption}:
[[] viages eared by & public assistance
incentive earnings or similar program (seotien 53-262 b(d1)
“| Cour-ordered ohild support payments (section 52-382b(h}} Amount claimed te be exempt
[| Alimony and support other than child suppor’ (section 62-262bin}} if less than the entire smount:
‘See Nole Regarding Exemption for Alimony and Support an baskpage 2.
funder Sr
. | ‘Date signed | Teleshare nuraber
Subsoribed and sworn
to. before me on:instructions
To Financial Institution To Clerk
1, Complete section 2 of this form snd (i) send 2 eapies 1. Atisch this form to each financial institution execution issued in a civil or
of form ard the financial institution exeoution fony family matter agains: a judgment debtor th. & natural persen.
tothe jucigment debtor and to eny secured party that is 2. Delivar the execution slong with this form: to the juclgment cceditor
party to 3. control agreement between thé financial requesting the execution.
institution andl such seoured party under article 9 of 3, Ifjudgment debtor completes and returns this form claiming an
pursuant to seotion 82-3670 of the General exemption, ente sara juddgm tor with ad
yemption, enter the appearance of the judgment debtor with addrass
nd £2) mail notice to judgment debtor ss st farh on page 1.
required by S1CFR213.5 and 242.7.
4, Sat matter down for shor calendar hearing.
2. If this claim of exemption is returned completed, fill out §. Complete section 7 below.
section 6 of this form and mail, within two business 8. Send file-stamped copy of this form xo judgnzent debtor and judgment
days, to the issuin, ‘s office at the address of ereditor.
court indicated on the front side. See additional 7. Aher hearing, send copy of ary order entered to the financial institution.
instrustions on the Financist institution execution form,
Note Regarding Exemption for Alimony and Support
Alimony and Support, other than child support, are exempt only to the following extent:
The amount of alimony and suppor, offer than child support, that may be cuhjeet to levy or ather withholding for payment of & judgment ic
the lecosr of (1) bventy-five percent of the individual's disposable esmings for that week, or (2) the smount by which the individual's
disposable eamings-for that week exosed fony tiniso the higher of (A) the federal minimum hourly wage under Section &/s){1) of the Fair
Labor Standards Act of 1933, U.S... Title 29, Section 208/a}/1), or {B), the state minimum hourly wage under subseston (i of Section
24-58, in affect at the time tie earnings are payable.
Section §2-350a(4) of the Sonnscticut General Steiuies defines “dispocahle eaminge” as that part of the earnings of sn individual eemaining
after the deduction fron those eamings of amaunta required fo be withheld for payment of federal income and émploynient taxes, normal
caticement contibutions, union duee and inifistion feeo, group life insurance premiums, health insurance. aremiunis and fed'sras tax Jevies.
Section 5 — Proper Officer Must Complete This Section
Ware and fbe of proper smear |. OPEERCCE On Aenea T
Section.6 — (To be completed by financial institution upon return of exemption claim form)
Date cisim recetved Taaied be court ‘Name of fnandal hetitulion ee nuner
Bor Teepncas mu
“Section ? — “Notice To Judgment Debtor And J 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 ofhesrng Tine ches Ig oO =m. Counrcom
Signed (assistant lem Dale signed
Order
The Gour/Magistrate, having held = hes
wy to determine the issues raised by this claim, hereby orders thst:
Magistrate
CIID PMIDEFEMy Suppor Mapirala isp svareAcsman CaM)
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with she Amerigans with Dis,
aesomir ed.
2s ACTIADAI.
ion in accordance with the ADA, contact a cour clark or an ADA contact person lis
Print Form Page 2 of 2 Reset Form
JD-CN-26A page 2j Sev. 1
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FINANCIAL INSTITUTION EXECUTION ” STATE OF CONNECTICUT (Ae TE i PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT APEEABA® WHO IS A NATURAL PERSON, www.jud.ct.gov APPLICATION AND EXI . . o . JD-CV-24 Rev. 245 ECUTION (See page 2 for instructions to financial institution ION ltl HA C.G.S. §§ 52-3660, 52-3675 and ADA Notice) Exissu PA.147, 149 Instructions - Judgment Creditor Or Attorney Instructions - Clerk 1. Type or print legibly. 1. Check the file to ensure thal the information provided 2. Compiete the application section; prepare original and 2 copies. on the application is corect. 3, Complete section 1 of the Exemption Claim Form, JO-CV-24a and altach to this form. 2. Sign original execution. 4. Prosent original and 1 copy to clerk of court, Retain a copy. _-3. Return original to applicant, retain a copy for file. ‘Address af court, P<] Judicial aistrict i Dockel number — Bridgeport Judicial District 1061 Main Street Bridgeport, CT 0660477 Housing session al FBTCV176061471 Name and malling address of Judgment Creditor or Altorney (To be completed by Judgment Creditor) T 7 Discover Bank c/o SCHREIBER/COHEN, LLC 53 Stiles Road, Suite,A102 Salem, NH 03079 L I Name(s) and address(es) of udgment creditors) Discover Bank C/O Discover Products inc 6500 New Albany Road East New Albany. OH 43054 Name(s) and address(es) of dudgment Debtor(s) MICHAEL PATRICK s ©) 339 MOOSE HILL RD MONROE, CT 06468-2412 Dale of judginent 04/27/17 4. Total amount pad {f any) $0.00 ‘Application fees pald for prior executions on this Judgment 3968025 Feld] 3. Amount of judgment, costs and fees (Add T and a) 9569.68 - Applation fee for inancianinstilulion execution {ifhat walved by the cout $105 %. Other count ordered postjudgment costs and fees > Application ToT tens. $0.00 $0.00 $9674.68 ‘Check if applicable ‘2! Ts this judgment arising out of services rendered at ahosphtal? @, [X]No [_] Yes postjudgment interest was ordered:by the court Ifthis is a judgment arising out of services rendered at a hospilal, has a stay of a financial institution execution been D Ne oD Ye entered pursuant lo an installment payment order? ° es Ifa stay of a financial institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? 7 Yes (Specify): Defendant defaulted on payment. ey) Dale signed Telephone number ——— : gis l(7 1-800-423-8142 Finangiatinstitution Execution Toal roper officer, Whereas on said Date of Judgment the above-named Judgment 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 receipt 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 office, 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(b) of the General Statutes of any nonexempt debt due said Judgment Debtor(s), which sum shall not exceed the total Unpaid judgment, costs and fees as stated above, plus postiudgment interest as ordered by the court, if applicable, plus the application fee and other court ordered postjudgment costs and fees and your own fee. After having made such demand you are 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 whom 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 Statutes. You shall not serve more than one financial institution execution per judgment debtor at a time, including copies thereof, After service of an execution on one For Court Use Only financial institution, you shall not serve the same execution or a copy thereof upon 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 to satisfy 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 thereof 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 -376b (c) of the General Statues (sixty days or, with regard to federal benefits, such greater period as required by federal law). Ifno such deposit was mage, you may subsequently serve the same execution or a copy thereof upon such institution, provided the execution has np expired, or otherwise become unenforceable. Hereof fail not, and make dugretu ith your doings thereon, according tp law. Signed (Assistant Clerk) Date sired Rel (7 Pane 4 af? FINANCIAL INSTITUTION EXECUTION PROCEEDINGSNOTE: 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 Is A Natural Person . If any funds are removed from the judgment debtor's account pursuant to subsection (c) of section 52-367b of the General Statutes, complete section II of the accompanying Exemption Claim Form (JD-C\V-24a) and (1) send, forthwith, 2 copies of both this form-and the Exemption Claim Form 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 ahy such secured party with respect to the affected accounts on the records of your institution and (2) mail notice to the judgment debtor as required by 31CFR212.6 and 212.7. N 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 federal Railroad Retirement Board or the federal Office of Personnel Management, unemployment compensation benefits exempt under'section 52-352b of the Connecticut General Statutes, or child support payments processed and received pursuant to Title. IV-D of the Social ‘Security Act were made to the judgment debtor's account during the look-back period of either the sixty-day period preceding the date that thé execution was served on you, or, with regard to féderal 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 judgment:debtor's account if required by any other provision of law or by a court order. The judgment debtor shall have full and customary access’ to’ such funds left in the judgment debtor's account. You .may notify the judgment creditor that funds have been left in the judgment ‘debtor's account pursuant to this provision. Nothing herein shall alter the exempt status of funds which are exenipt from execution under subsection (a) of section §2-367b of the General Statutes. or under any other provision of state or federal law, or the right of'a-judgment.debtor to claim 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 hold the amount removed from the judgment debtor's account pursuant to this execution for fifteen days from the date you mail the copies of this form and the Exemption Claim 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 returns 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 ofder 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 to the judgment debtor’s account. 5: If you do not receive a claim of exemption or secured party claim-notice within fifteen days of the mailing to the judgment debtor and any secured party of the execution and Exemption Claim Form you: must, upon demand, forthwith pay the serving officer the amount removed from the judgment debtor's account. a . 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 and you fail or refuse to do so, you shall 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 shall be liable in an action therefor to the judgment creditor(s) name in the execution for the amount of nonexempt monies which you fail or refuse to pay over, excluding funds of up to one thousand dollars which you in good faith allowed the judgment debtor to access pursuant to subsection (c) of section 52-367b of the General Statutes. nN“ 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 shall be liable in an action therefor to the judgment debtor for any exempt monies so paid. 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 shall be liable in an action therefor to the judgment debtor for any exempt monies so. paid and you shall refund or waive any charges of fees by you, including, but not limited to, dishonored check fees, overdraft fees or minimum balance service charges and legal process fees, which were assessed as a result of such payment of exempt monies. 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 al wivv.jud.ct.gov/ADA. JD-CV-24 (baci/page 2) Rev, 2-15 Page 2 of 2EXEMPTION CLAIM FORM FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTIOUT 48 3 ge ia yeaa 2-3805, 629820, £2-3615, SEE INSTRUCTIONS ON BACHPAGE 2 weve jud.et.gov msi £2. SO6IaN1p Name sng agdrese of cuegmeni Debtor or Aatomey {To oe completzd oy josgment creator ar sttomey) For court ose cay MXHIPEX iH OT 1 To: MICHAEL J PATRICK 339 MOOSE HILL RD MONROE, CT 06468-2412 L J Section 1 — (To be completed by judyment creditor) Tseagraphical Nama anid sddress of Coun (MLAMDEr, ON . 4, Town and zie Cove} Judicial Hi = 3 * * ’ xX fuaicial Session a HES cer Bridzenort Judicial District 1061 Main Street Bridzenort. CT 06604 ame of aac Name of Juagmen: Oealor Docket number Discover Bank v, MICHAEL J PATRICK MICHAEL J PATRICK FBTCV176061471 Section 2— {To be completed by financial institution - see instructions on back/paye 2) Name and address of inancial insiuvon te wtih exempron-cialm ji ay) Is fo GS reamed Date of malting to Jaen Deer Taste Dagiie of the Account Murnoens) shest|s) Section 3 3—Notice To Judgment Debtor As a result of a judgment entered against you, the attached execution has. been issued agsinst funds deposited by you inthe financial institution named above. To camply with this execution, the financial instiution has-removed the amount of money indicated above from the account/s] listed above. THE MONEY IN YOUR ACCOUNT(S) MAY BE EXEMPT FROM EX! i execution by state statutes or by other laws or regulations of Connecticut or of the United States. A checklist amd a description of che most common exemptions established by Isa are set forth below, HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW. léyou wish fo claim thatthe monay in your account(s} is exempt by law from axgoution, you ntust fill out and sign before 3 proper official the Affidavit of Claim of Exemption below and mail or deliver this exemption elsin: form to the financial institution st the shove address. This form must be recsived by the financial. institution mo jater than 15 days from the DATE OF MAILING TC THE JUOGMENT DEBTOR indicated above. Upon reesipt cf this form the financial it vill send it te the Superior Court and the cour clerk will notify you and the judgment eraditor of the date on which 3 = hesring will be held by the court to determina the issues raised by your claim. SECTION 4 — AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW I, 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: ("%" ail that eopsy fo the funds contained in this account) and [7] Seis! Security benefits (section $2-262bigi |] Private pension, trust, retirement, or madical sa [_] Unemployment benefits ( socount payments [sections $2-321a, 62-3 3 oO Workers Compensation benaiits (5 oO Heskh or disability msuranse psynrents {section 52-352b{2)) [_] Veteran's benefits (seotion €2-252bi0)) [J An smauni in the bank not to axo22d $1000 (section §2-242b(1}) [] Fublic Assistance payments (section 52-362b(d 1} oO Other slain of exempt funds jExpian oasis for clin sf exemption}: [[] viages eared by & public assistance incentive earnings or similar program (seotien 53-262 b(d1) “| Cour-ordered ohild support payments (section 52-382b(h}} Amount claimed te be exempt [| Alimony and support other than child suppor’ (section 62-262bin}} if less than the entire smount: ‘See Nole Regarding Exemption for Alimony and Support an baskpage 2. funder Sr . | ‘Date signed | Teleshare nuraber Subsoribed and sworn to. before me on:instructions To Financial Institution To Clerk 1, Complete section 2 of this form snd (i) send 2 eapies 1. Atisch this form to each financial institution execution issued in a civil or of form ard the financial institution exeoution fony family matter agains: a judgment debtor th. & natural persen. tothe jucigment debtor and to eny secured party that is 2. Delivar the execution slong with this form: to the juclgment cceditor party to 3. control agreement between thé financial requesting the execution. institution andl such seoured party under article 9 of 3, Ifjudgment debtor completes and returns this form claiming an pursuant to seotion 82-3670 of the General exemption, ente sara juddgm tor with ad yemption, enter the appearance of the judgment debtor with addrass nd £2) mail notice to judgment debtor ss st farh on page 1. required by S1CFR213.5 and 242.7. 4, Sat matter down for shor calendar hearing. 2. If this claim of exemption is returned completed, fill out §. Complete section 7 below. section 6 of this form and mail, within two business 8. Send file-stamped copy of this form xo judgnzent debtor and judgment days, to the issuin, ‘s office at the address of ereditor. court indicated on the front side. See additional 7. Aher hearing, send copy of ary order entered to the financial institution. instrustions on the Financist institution execution form, Note Regarding Exemption for Alimony and Support Alimony and Support, other than child support, are exempt only to the following extent: The amount of alimony and suppor, offer than child support, that may be cuhjeet to levy or ather withholding for payment of & judgment ic the lecosr of (1) bventy-five percent of the individual's disposable esmings for that week, or (2) the smount by which the individual's disposable eamings-for that week exosed fony tiniso the higher of (A) the federal minimum hourly wage under Section &/s){1) of the Fair Labor Standards Act of 1933, U.S... Title 29, Section 208/a}/1), or {B), the state minimum hourly wage under subseston (i of Section 24-58, in affect at the time tie earnings are payable. Section §2-350a(4) of the Sonnscticut General Steiuies defines “dispocahle eaminge” as that part of the earnings of sn individual eemaining after the deduction fron those eamings of amaunta required fo be withheld for payment of federal income and émploynient taxes, normal caticement contibutions, union duee and inifistion feeo, group life insurance premiums, health insurance. aremiunis and fed'sras tax Jevies. Section 5 — Proper Officer Must Complete This Section Ware and fbe of proper smear |. OPEERCCE On Aenea T Section.6 — (To be completed by financial institution upon return of exemption claim form) Date cisim recetved Taaied be court ‘Name of fnandal hetitulion ee nuner Bor Teepncas mu “Section ? — “Notice To Judgment Debtor And J 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 ofhesrng Tine ches Ig oO =m. Counrcom Signed (assistant lem Dale signed Order The Gour/Magistrate, having held = hes wy to determine the issues raised by this claim, hereby orders thst: Magistrate CIID PMIDEFEMy Suppor Mapirala isp svareAcsman CaM) ADA NOTICE The Judicial Branch of the State of Connecticut complies with she Amerigans with Dis, aesomir ed. 2s ACTIADAI. ion in accordance with the ADA, contact a cour clark or an ADA contact person lis Print Form Page 2 of 2 Reset Form JD-CN-26A page 2j Sev. 1