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FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT a i li
, PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT *. | i i
® WHOIS A NATURAL PERSON, www,jud.ct. gov APFEABA
APPLICATION AND EXECUTION [
‘Spoves Rev ots (See page 2 for instructions to financial institution LCT
C.G.S. §§ 52-356b, 52-9675 and ADA Notice) *EXISSUE*
PA. 14-7, 14-9 4
Instructions Judgment Creditor Or Attorney Instructions - Clerk
1. Type or print legibly.
2 Complete the application section; prepare original and 2 copies.
‘3. Complete section 1 of the Exemption Claim Form, JD-CV-24a and attach to this form.
4. Present original and 1 copy to clerk of court. Retain a copy. _
4. Check the file fo ensure that the information provided
on the application is correct.
2 Sign original execution.
3. Retum original to applicant, retain a copy for:
piteiess of court 123 Hoyt St, Stamford, CT Oo%05 DA sudicial cstrict Geographic iggt number ar ON
5 Housing session [_] aurmber SCe0888351 5021SAZ.
Name and mailing address of Jagmnent ‘Creditor or Attorney (To be completed by Judgment Creditor)
Cr 7
SCHREIBER / COHEN LLC ©
53 STILES ROAD OS
SUITE A102 A ge
SALEM NH 03079
L A
Name(s) and address(es) of Judgment Greditor(s)
2 MIDLAND FUNDING, LLC
3111 CAMINO DEL RIO NORTH SUITE 103 SAN DIEGO CA 92108
$35.00
Total amount paid (if any)
$1,607.92
$0.00
[7 Application fees paid for prior executions on this judgment
S.Total amount unpaid (Subtract 4 from 3)
§ | Name(s) and address(es) of Judgment Debtor(s)
3 OLIVER BOYKIN
s 261 MONTAUK DR APT 411 STAMFORD CT 06902
B [Dateofjedgment 7+. Amount ofjudament (include, where applicable, | 2
< | 4/18/2017 $1,541.27 Breludgment interest and "| 494 65 $1,642.92
6. Application fee for financial institution execution (ifnot waived by the court) .
$105.00
a 8, Other court ordered pastjudgment costs and fees 12 ms 5,6, 7and 8
. $0.00 $1, 712.92
ia tis judgment arising out of Services rendered ata hospital? @]
this sa Judgment arsing out of services rendered a a hospital, has stay of nancial Instution execution bean
entered pursuant to an installment payment order?
[3] No
Check if applicable ta
[CJ postiudgment interest was ordered by the court
[no [J Yes
Yes
fa stay of a financial institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? {0
No [] Yes (Specify): DEFENDANT DEFAULTED ON PAYMENT
‘Signed (Judgment Creditor or Afomey) Date signed Telephone number
417302 HEATHER QUIGLEY WALLACE 4118/2019 8004238142
Financial Institution Execution
To any proper officer, .
‘Whereas on sald Date of Judgment the above-named Judgment Creditors) 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 postjudgment 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. Sald 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
financial institution, you shall not serve the same execution or a copy thereof upon anather 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 executlon, 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 made, you may subsequently serve the same execution or a copy thereof
upon such institution, provided the execution has not expired or otherwise become unenforceable.
Hereof fail not, and make due return of this writ with your doings thereon, according to law.
Signed (Assistant rk) Date
diqiza De Le Assistant Clecle
Regina M. Gilroy
2H9
Page 1 of 2 po 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
. 1. 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 Il of the accompanying Exemption Claim Form (JD-CV-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 any 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.
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 secutity income benefits, exempt benefits pald 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 [V-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 the execution was served 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 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 exempt from execution under subsection (a) of section 52-367b
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 mall
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 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 to
the judgment debtor's account.
5. lf 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 monles 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.
7. lf 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 neéd a reasonable accommodation in accordance with the
ADA, contact a court clerk or an ADA contact person listed at www.jud.ct gov/ADA.
. -
[ JD-CV-24 (back/page 2) Rev, 2-15 . Page 2 of 2\
EXEMPTION CLAIM FORM,
FINANGIAL INSTITUTION EXECUTION . STATE OF CONNECTICUT
f JD-CV-24A Rev. 1-17 SUPERIOR COURT: .
C.GS. 31-68(), §2-321a, §2-350a, 52-352b, 52-361a, SEE INSTRUCTIONS ON BACK/PAGE 2 www.jud.ct.gov
52-367b, 29 U.S.C. 206(a)(1)
Name and address of Judgment Debtor or Attorey
(To be completed by judgment creditor or attorney)
To: © 1
OLIVER BOYKIN .
261 MONTAUK DR APT 411
STAMFORD CT 06902 LACT
L J
Section 1 — (To be completed by judgment creditor)
Geographical” Thane ie and address of Court (Number, Street, Town and Zip Code)
Judicial Housing
EX] istrict session [1] NO Number Fee ohington Steect-Herora, oe aeres 123 Rovt St, Stamford, or, G10
Name of case ‘Name of Judgment Debtor Docket number
MIDLAND FUNDING, LLC vs. BOYKIN OLIVER BOYKIN see-sesssa1 FSTCVIT-
5o02z'saz
Section 2 — (To be completed by financial institution - see instructions on back/page 2)
Name and address of financial inetitution to which ‘exemption claim (if any) Is to be returned Date of mailing to Judgment Debtor
Last 4 Digits of the Account Number(s) Amount removed pursuant to execution
wT ‘Additional sheet(s) attached hereto and made a part hereof (if necessary).
Section 3 — Notice To Judgment Debtor
As a result of a Judgment entered against you, the attached execution has been issued against funds deposited by you in the
financial institution named above. To comply with this execution, the financial institution has removed the amount of money indicated
above from the account(s) listed 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 Connecticut or of the United States. A checklist and a description of the most
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 send it to the Superior Court and the court clerk will 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
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: (°X" all that apply to the funds contained in this account) .
{CJ Social Security benefits (section 52-352b(g)) (C Private pension, trust, retirement, or medical savings
{| Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, 52-352b(m))
{_] Worker's Compensation benefits (section 52-352b(g)) (J Health or disability insurance payments (section 52-352b(e))
([] Veteran's benefits (section 52-352b(q)) {_] An amount in the bank not to exceed $1000 (section 52-352b(r))
(J Public Assistance payments (section 52-352b(d)) {_] Other claim of exempt funds (Explain basis for claim of exemption):
(Wages earned by a public assistance recipient under an .
incentive earnings or similar program (section 52-352b(d))
(J Court-ordered child support payments (section 52-352b(h)) Amount claimed to be exempt
LJ Alimony and support other than child support* (section 52-352b(n)) if less than the entire amount:
*See Note Regarding Exemption for Alimony and Support on back/page 2.
Signed Date signed “Telephone number
‘Complete mailing address of Judgment Debtor ~
‘Subscribed and swom | 08 At (Town) , ‘Signed (Notary Public, Commissioner of Superior Court)
to before me on :
Page 1 of 2Instructions
To Financial Institution
1. Complete section 2 of this form and (1) send 2 coples
of this form and the financial institutian execution form
to the judgment debtor and to 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.
. If this claim of exemption is returned completed, fill out
section 6 of this form and mail, within two business
days, to the issuing clerk's office at the address of
court indicated on the front side, See additional
Ny
To Clerk
1. Attach this form to each financial institution execution issued in a civil or
family matter against a judgment debtor that is a natural person.
2. Deliver the execution along with this form to the judgment creditor
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.
4, Set matter down for short calendar hearing.
5. Complete section 7 below.
6. Send file-stamped copy of this form to judgment debtor and judgment
creditor.
7. After hearing, send copy of any order entered to the financial institution,
instructions on the financial 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 support, other than child support, that may be subject to levy or other withholding for payment of a judgment is
the lesser of (1) twenty-five percent of the individual's disposable eamings for that week, or (2) the amount by which the individual's
disposable eamings 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. Title 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 eamings.are payable.
Section 52-350a(4) of the Connecticut General Statutes defines "disposable eamings" as that part of the eamings 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
lame and title of proper officer Date of service on financial i e number
Section 6 — (To be completed by financial institution upon return of exemption claim form)
Date claim received ‘Date mailed to 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.
—
‘Signed (Assistant Glen) Signed
Order . .
The Court/Magistrate, having held a hearing to determine the issues raised by this claim, hereby orders that:
By the Court (Name of Judge/Family Support Magistrate/agistrate)
Judge O Fsm CO Magistrate
Signed (Judge/amily Support SREMIEessacey pe Clerk} Datesigned
ADA NOTICE ‘
The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable
accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www,jud.ct.gov/ADA,
JD-CV-24A (page 2) Rev, 1-17
Page 2 of 2
at
Preview
FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT a i li , PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT *. | i i ® WHOIS A NATURAL PERSON, www,jud.ct. gov APFEABA APPLICATION AND EXECUTION [ ‘Spoves Rev ots (See page 2 for instructions to financial institution LCT C.G.S. §§ 52-356b, 52-9675 and ADA Notice) *EXISSUE* PA. 14-7, 14-9 4 Instructions Judgment Creditor Or Attorney Instructions - Clerk 1. Type or print legibly. 2 Complete the application section; prepare original and 2 copies. ‘3. Complete section 1 of the Exemption Claim Form, JD-CV-24a and attach to this form. 4. Present original and 1 copy to clerk of court. Retain a copy. _ 4. Check the file fo ensure that the information provided on the application is correct. 2 Sign original execution. 3. Retum original to applicant, retain a copy for: piteiess of court 123 Hoyt St, Stamford, CT Oo%05 DA sudicial cstrict Geographic iggt number ar ON 5 Housing session [_] aurmber SCe0888351 5021SAZ. Name and mailing address of Jagmnent ‘Creditor or Attorney (To be completed by Judgment Creditor) Cr 7 SCHREIBER / COHEN LLC © 53 STILES ROAD OS SUITE A102 A ge SALEM NH 03079 L A Name(s) and address(es) of Judgment Greditor(s) 2 MIDLAND FUNDING, LLC 3111 CAMINO DEL RIO NORTH SUITE 103 SAN DIEGO CA 92108 $35.00 Total amount paid (if any) $1,607.92 $0.00 [7 Application fees paid for prior executions on this judgment S.Total amount unpaid (Subtract 4 from 3) § | Name(s) and address(es) of Judgment Debtor(s) 3 OLIVER BOYKIN s 261 MONTAUK DR APT 411 STAMFORD CT 06902 B [Dateofjedgment 7+. Amount ofjudament (include, where applicable, | 2 < | 4/18/2017 $1,541.27 Breludgment interest and "| 494 65 $1,642.92 6. Application fee for financial institution execution (ifnot waived by the court) . $105.00 a 8, Other court ordered pastjudgment costs and fees 12 ms 5,6, 7and 8 . $0.00 $1, 712.92 ia tis judgment arising out of Services rendered ata hospital? @] this sa Judgment arsing out of services rendered a a hospital, has stay of nancial Instution execution bean entered pursuant to an installment payment order? [3] No Check if applicable ta [CJ postiudgment interest was ordered by the court [no [J Yes Yes fa stay of a financial institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? {0 No [] Yes (Specify): DEFENDANT DEFAULTED ON PAYMENT ‘Signed (Judgment Creditor or Afomey) Date signed Telephone number 417302 HEATHER QUIGLEY WALLACE 4118/2019 8004238142 Financial Institution Execution To any proper officer, . ‘Whereas on sald Date of Judgment the above-named Judgment Creditors) 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 postjudgment 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. Sald 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 financial institution, you shall not serve the same execution or a copy thereof upon anather 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 executlon, 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 made, you may subsequently serve the same execution or a copy thereof upon such institution, provided the execution has not expired or otherwise become unenforceable. Hereof fail not, and make due return of this writ with your doings thereon, according to law. Signed (Assistant rk) Date diqiza De Le Assistant Clecle Regina M. Gilroy 2H9 Page 1 of 2 po 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 . 1. 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 Il of the accompanying Exemption Claim Form (JD-CV-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 any 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. 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 secutity income benefits, exempt benefits pald 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 [V-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 the execution was served 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 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 exempt from execution under subsection (a) of section 52-367b 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 mall 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 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 to the judgment debtor's account. 5. lf 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 monles 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. 7. lf 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 neéd a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct gov/ADA. . - [ JD-CV-24 (back/page 2) Rev, 2-15 . Page 2 of 2\ EXEMPTION CLAIM FORM, FINANGIAL INSTITUTION EXECUTION . STATE OF CONNECTICUT f JD-CV-24A Rev. 1-17 SUPERIOR COURT: . C.GS. 31-68(), §2-321a, §2-350a, 52-352b, 52-361a, SEE INSTRUCTIONS ON BACK/PAGE 2 www.jud.ct.gov 52-367b, 29 U.S.C. 206(a)(1) Name and address of Judgment Debtor or Attorey (To be completed by judgment creditor or attorney) To: © 1 OLIVER BOYKIN . 261 MONTAUK DR APT 411 STAMFORD CT 06902 LACT L J Section 1 — (To be completed by judgment creditor) Geographical” Thane ie and address of Court (Number, Street, Town and Zip Code) Judicial Housing EX] istrict session [1] NO Number Fee ohington Steect-Herora, oe aeres 123 Rovt St, Stamford, or, G10 Name of case ‘Name of Judgment Debtor Docket number MIDLAND FUNDING, LLC vs. BOYKIN OLIVER BOYKIN see-sesssa1 FSTCVIT- 5o02z'saz Section 2 — (To be completed by financial institution - see instructions on back/page 2) Name and address of financial inetitution to which ‘exemption claim (if any) Is to be returned Date of mailing to Judgment Debtor Last 4 Digits of the Account Number(s) Amount removed pursuant to execution wT ‘Additional sheet(s) attached hereto and made a part hereof (if necessary). Section 3 — Notice To Judgment Debtor As a result of a Judgment entered against you, the attached execution has been issued against funds deposited by you in the financial institution named above. To comply with this execution, the financial institution has removed the amount of money indicated above from the account(s) listed 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 Connecticut or of the United States. A checklist and a description of the most 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 send it to the Superior Court and the court clerk will 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 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: (°X" all that apply to the funds contained in this account) . {CJ Social Security benefits (section 52-352b(g)) (C Private pension, trust, retirement, or medical savings {| Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, 52-352b(m)) {_] Worker's Compensation benefits (section 52-352b(g)) (J Health or disability insurance payments (section 52-352b(e)) ([] Veteran's benefits (section 52-352b(q)) {_] An amount in the bank not to exceed $1000 (section 52-352b(r)) (J Public Assistance payments (section 52-352b(d)) {_] Other claim of exempt funds (Explain basis for claim of exemption): (Wages earned by a public assistance recipient under an . incentive earnings or similar program (section 52-352b(d)) (J Court-ordered child support payments (section 52-352b(h)) Amount claimed to be exempt LJ Alimony and support other than child support* (section 52-352b(n)) if less than the entire amount: *See Note Regarding Exemption for Alimony and Support on back/page 2. Signed Date signed “Telephone number ‘Complete mailing address of Judgment Debtor ~ ‘Subscribed and swom | 08 At (Town) , ‘Signed (Notary Public, Commissioner of Superior Court) to before me on : Page 1 of 2Instructions To Financial Institution 1. Complete section 2 of this form and (1) send 2 coples of this form and the financial institutian execution form to the judgment debtor and to 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. . If this claim of exemption is returned completed, fill out section 6 of this form and mail, within two business days, to the issuing clerk's office at the address of court indicated on the front side, See additional Ny To Clerk 1. Attach this form to each financial institution execution issued in a civil or family matter against a judgment debtor that is a natural person. 2. Deliver the execution along with this form to the judgment creditor 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. 4, Set matter down for short calendar hearing. 5. Complete section 7 below. 6. Send file-stamped copy of this form to judgment debtor and judgment creditor. 7. After hearing, send copy of any order entered to the financial institution, instructions on the financial 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 support, other than child support, that may be subject to levy or other withholding for payment of a judgment is the lesser of (1) twenty-five percent of the individual's disposable eamings for that week, or (2) the amount by which the individual's disposable eamings 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. Title 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 eamings.are payable. Section 52-350a(4) of the Connecticut General Statutes defines "disposable eamings" as that part of the eamings 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 lame and title of proper officer Date of service on financial i e number Section 6 — (To be completed by financial institution upon return of exemption claim form) Date claim received ‘Date mailed to 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. — ‘Signed (Assistant Glen) Signed Order . . The Court/Magistrate, having held a hearing to determine the issues raised by this claim, hereby orders that: By the Court (Name of Judge/Family Support Magistrate/agistrate) Judge O Fsm CO Magistrate Signed (Judge/amily Support SREMIEessacey pe Clerk} Datesigned ADA NOTICE ‘ The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www,jud.ct.gov/ADA, JD-CV-24A (page 2) Rev, 1-17 Page 2 of 2 at