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FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT ALUN
PROCEEDINGS .- JUDGMENT DEBTOR SUPERIOR COURT EE
WHO IS A NATURAL PERSON, www jud.ct.gov
APPLICATION AND EXECUTION (See page 2 for instructions to financial institution) ea
CGS, §§ 52.850, 52387 14-01516-0/BXA “EXISSUE*
Instructions - Judgment Creditor Or Attorney Instructions - Clerk
1. Type or print legibly. 1. Check the file to ensure that the information provided
2. Complete’ the application section; prepare original and 2 copies. ‘on the application is correct.
3. Complete section 1 of the Exeniption Claim Form, JD-CV-24a and attach to this form. ‘2. Sign original execution.
i fo‘clerk of court. Retain a tépy. .3: Retumn original to applicant,.relain:a copy for file.
Judicial district Geographic | Oockel nuinbar
‘P.O. Box 247, Litchfield, CT 06759 Housing session _[] number, _LLI-CV-14-6011202-S
‘Name and mailing address of Jadgment Creditor. or Ailoiney (To be completed By Judgment Crediton
rc : 7
TOBIN MELIEN & MAROHN
45 Court Street
__ New Haven, CT 06511
[Name(s Fase ‘of Judgment Greditor(s).
3 - UNIFUND CORPORATION, clo Tobin Mellen & Marohn, 45 Court St. New Haven cT
§ Nan jamal) ands ARTES eSH oT Sedge DENTS) = ==> -
| MELISSA HICKCOX, 1099 Hickory Hill Road, , Thomaston, Connecticut. 06787
oS
© |oxeotudarent nade, sence aint of coals 3, Amount ofjudgment
< | 3/16/15: stemay fog) $400.60 _. _.$15,729:88 _
ri 3 rountunpiald. (Subtract 4 Wom a) | 6: Application fee for financial institution execution (if not walved by the court)
_ $15, 729.88 _ . $100.00.
‘Olner. court-ordered postjudgment ‘costs Bnd fees ” ByFolal.of items: 6, 6and 7” [ Check If applicable ~
P oP eee - i postjudgment interest was ordered by the court
is this judgment arising out of Services renderad at a hospital?
Dyno (Yes
If this is a judgment arising out of services rendered at a hospital, has a stay of a financial institution execution been
entered pursuant to.an installment payment order? [No OYes
|. a stay.of a financial institution execution has been entered, has ‘Judgment Debtor defaulted on an installment payment order?
[No -[] Yes (Specify): NON-COMPLIANCE PAYMENT ORDER
sSigned {Judgment Creditor or Attomey) ~ ~ | Date’signed ‘Telephone‘number
William L. Marohn_ yf 5/42/2045. 203-777-6660:
Financial Institution Execution
To any proper 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 finat
county, upon an employee of such a branch office, such employee and such by
institution in accordance-with regulations adopted by the commissioner of bi
general statutes of any nonexempt debt due said Judgment Debtor(s), which:sa
fees as stated above, plus postjidgment interest as ordered by the court, if app!
ial institution has one or more branch,
Ne total unpaid judgment; costs and
i the application fee and other court ordered
ffices within your
ment ant to s -367b(b) of the
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 . — For Court Use Only
endorsed thereon, with the financial institution officer upon whom such demand was-made. °
Said sum shail 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 FI FICE OF THE CLERK
one 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 SUPERIOR cau JRT
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 JUN 1 2 2015
from the receipt by you of such execution. of
Hereof faijpot, and make due return of this writ with your doings thereon, according;to law. UDICI, AL DI STR ( Ci
Se. (etles— re |" [> 1S __| OF LITCHFIELD
Page 1 of 2 FINANCIAL INSTITUTION EXECUTION PROCEEDINGS
lotNOTE: 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
41. If any funds 2 ‘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-CV-24a) and send, forthwith, 2 copies of both this form and the
Exemption Claim 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.
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. electronic direct deposits that are feadily:identifiable. as exempt federal veterans’ benefits, Social security benefits,
including, but not limited ‘to, retirement; ‘Survivors! and disability benefits, supplemental security. income benefits 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 thirty-day period preceding the date that the execution was served on you, you’shall leave the lesser of the account balance or one
thousand dollars. in.the judgment.debtors’. account; provided nothing in this subsection shall be construed to limit your right, or obligation
to remove such'funds from the debtor's account if required by any other provision of law or by @ court order. The judgment debtor shall
have access to:such funds left in the judgment ebtor's account: You may notify the judgment creditor that funds ‘have been left in the
.judgment debtors: 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-othef provision of state or federal law, of 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 tegard to the funds in the judgment debtor's account.
3. You must hold the: amount femoved fromthe judgment debtors account pursuant to: this executionfor fifteen days from the date you mail
the copies ofthis formn 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. Ifyou 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:.éxecution and Exemption. Claim Form you must, upon demand, forthwith pay the serving officer the’ amount
removed from the judgment debtor's account.
6. If no, exemption claim or secured party. claim noticé 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-ori the execution and you fail or refuse to da so, you-shall be liable:in an
action therefor to. the: judgement’ creditor(s) named in the-execution for the-amount of nonexempt moriies which you fail or refuse: to pay.
over. If no exemption claim is, filed 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 créditor(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. 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 éxempt monies.
D-CV-26 (back/page 2) Rev: 12:09 Page 2 of 2EXEMPTION CLAIM FORM
STATE OF CONNECTICUT
FINANCIAL INSTITUTIOI
ID-CV-24A, Rev, Ms TON EXECUTION SUPERIOR COURT ,_&
C.G.S. 31-58()), 52-321, 62-350a, 52-362b, 62-3614, SEE INSTRUCTIONS ON BACKIPAGE 2 www,jud.ct.gov
52-387b, 29 U.S.C. 208(aX(1) : Y
‘Name and addréss of Judgment Debtor or Attorney
(To be completed by judgment creditor or attomey)
To. q
MELISSA HICKCOX
1099 Hickory Hill Road
Thomaston, Connecticut 06787
Section 1 — (To'be completed by judgment creditor)
“judicial Housing Geooreplcal Name'and address of Cold (Nomber, Street; Town and Zip Code)
Diva _O) session C1 Nitber LITCHPIELD-AT LiTCHEIELD, P.O. Box 247 Liichfiti. o6r6s
‘Name of case Name ofi Judgment Debtor~ ~ . “| Docket number.
INIFUND CORPORATION v. MELISSA HICKGOX MELISSA Hickcox LLI-CV-14-6011202-5
‘Section 2— (To be completed by financial institution - see instructions on back/page 2)
[financial msiitulion to, whickvexemplion claim (i any)iso.be relumed ‘Dale‘ofmailing to Judgment Dabior
“Test 4 Digits ofthe Account Number) ‘Amount rameved pursuant fo execution “Amountand lype of ready identifiable exenipl fands nol removed
oO 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. 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 accounts) 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 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 forward 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
1, 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)
{J Social Security. benefits (section 52-352b(g)) {JJ Private pension, trust, retirement, or medical savings
{_] Unemployment benefits (section 52-352b(g)) account payments (sections 52-3214; 52-352b(m))
[_] Worker's Compensation benefits (section'52-352b(g)) (CJ Health or disability insurance payments (section 52-352b(e))
[J Veteran's benefits (section 52-352b(g)) [_] An amount in the bank riot to exceed $1000 (section 52-352b(r))
L_] Public Assistance payments (section 52-352b(d)) [2 Other claim of-exempt funds (Explain basis for claim of exemption):
[] Wages* (section 52-361)
oO Wages earned by a public assistance recipient under an
incentive eamings or similar program (section 52-352b(d)) Amount claiméd to be exempt
(CJ Court-ordered ‘child support payments (section 52-352b(h)) if less than the entire amount:
LJ Alimony and support other than child support* (section 52-352b(n))
*See Note Regarding Exemption for Wages and Alimony on back/page 2.
Signed Dale signed Telephone number
“Complate mailing address of Judgment Deblor
Subscribed and sworn Date At (Town) [Signed (Notary Public, Commissioner of Superior Court}
to before me on * [
Page 1 of 2Instructions
To.Financial Institution To Clerk
1. Complete section 2 of this form-and send:2 copies. 1. Attach this form to-each financial institution execution issued in a civil or
of this form and the financiat institution execution family matter against a judgment debtor that is a natural person.
form‘to the judgrient debtor and to. any secured 2. Deliver the execution along with this form tothe judgment creditor
-Party that is party to a control agreement between requesting the execution.
the'financial institution and such secured party 3. If judgment debtor completes and returns this form claiming an
under article’ 9 of title 42a pursuant to'section : exemption, enter the appearance of the judgment-debtor with address.
52-367b of the General Statutes. set forth on page 1. \
If this claim of exemption is returned completed, fill ‘ Corte etn boone hearing.
out section 4 of this form and mail,. within two. os + “
business days, to the issuing clerk’s office at the 6. Send fie stamped: Copy of this form to judgment debtor and judgment
address of court indicated on the-front side. See 4 sa) inetit it
additional instructions on the financial institution. 7. After hearing, send copy of any order entered to the financial institution.
execution form.
Nv
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 1esser of (1) twenty-
five per cent-of the individual's disposable earnings 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. tit: 29, Section-206(a)(1), or (B); the state minimum hourly wage under subsection (j) of Section 31-58, in effect at the time the
earnings.are payable. * toa * . - 8
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 earnings of amounts required to be withheld for payment of federal income.and employment
taxes, normal retirement.contributions, union dues and initiation fees, grouip life insurance premiums, health insurance premiums and
federal tax levies. -
Section 5 — Proper Officer Must Complete This Section
“Nate and tile of properofficer > > [ Dale oF service on tinandal institution: Telephone number
Dale claim reckived. Date mailed to court "[-Name of nancial insttulion
Section 6 — (To be completed by financial institution upon return of exemption claim form).
Section 7 — Notice To Judgment Debtor And Judgment Creditor: "
The assets in dispute are being held for (4 ) 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. © “ see . ‘
Dale or heating ‘Time of hearing ~ [Ta ‘Courtroom
west if ED _
“ADA NOTICE °
The Judicial Branch’of the State of Connecticit 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. gow/ADA.
Signed: (Assistant Clerk) ae Ba 7 ° "] Dale 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/Magistrate) .
i. . . [7 sudge (1 Fsm LI Magistrate
ianed: (dudge/Family Support Magisirate/Magistrate/Assistant Clerk)... .... _. bale signed ~~) be > ~
JD-CV-24A, (page 2) Rev, 4-13 Page 2 of 2
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FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT ALUN PROCEEDINGS .- JUDGMENT DEBTOR SUPERIOR COURT EE WHO IS A NATURAL PERSON, www jud.ct.gov APPLICATION AND EXECUTION (See page 2 for instructions to financial institution) ea CGS, §§ 52.850, 52387 14-01516-0/BXA “EXISSUE* Instructions - Judgment Creditor Or Attorney Instructions - Clerk 1. Type or print legibly. 1. Check the file to ensure that the information provided 2. Complete’ the application section; prepare original and 2 copies. ‘on the application is correct. 3. Complete section 1 of the Exeniption Claim Form, JD-CV-24a and attach to this form. ‘2. Sign original execution. i fo‘clerk of court. Retain a tépy. .3: Retumn original to applicant,.relain:a copy for file. Judicial district Geographic | Oockel nuinbar ‘P.O. Box 247, Litchfield, CT 06759 Housing session _[] number, _LLI-CV-14-6011202-S ‘Name and mailing address of Jadgment Creditor. or Ailoiney (To be completed By Judgment Crediton rc : 7 TOBIN MELIEN & MAROHN 45 Court Street __ New Haven, CT 06511 [Name(s Fase ‘of Judgment Greditor(s). 3 - UNIFUND CORPORATION, clo Tobin Mellen & Marohn, 45 Court St. New Haven cT § Nan jamal) ands ARTES eSH oT Sedge DENTS) = ==> - | MELISSA HICKCOX, 1099 Hickory Hill Road, , Thomaston, Connecticut. 06787 oS © |oxeotudarent nade, sence aint of coals 3, Amount ofjudgment < | 3/16/15: stemay fog) $400.60 _. _.$15,729:88 _ ri 3 rountunpiald. (Subtract 4 Wom a) | 6: Application fee for financial institution execution (if not walved by the court) _ $15, 729.88 _ . $100.00. ‘Olner. court-ordered postjudgment ‘costs Bnd fees ” ByFolal.of items: 6, 6and 7” [ Check If applicable ~ P oP eee - i postjudgment interest was ordered by the court is this judgment arising out of Services renderad at a hospital? Dyno (Yes If this is a judgment arising out of services rendered at a hospital, has a stay of a financial institution execution been entered pursuant to.an installment payment order? [No OYes |. a stay.of a financial institution execution has been entered, has ‘Judgment Debtor defaulted on an installment payment order? [No -[] Yes (Specify): NON-COMPLIANCE PAYMENT ORDER sSigned {Judgment Creditor or Attomey) ~ ~ | Date’signed ‘Telephone‘number William L. Marohn_ yf 5/42/2045. 203-777-6660: Financial Institution Execution To any proper 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 finat county, upon an employee of such a branch office, such employee and such by institution in accordance-with regulations adopted by the commissioner of bi general statutes of any nonexempt debt due said Judgment Debtor(s), which:sa fees as stated above, plus postjidgment interest as ordered by the court, if app! ial institution has one or more branch, Ne total unpaid judgment; costs and i the application fee and other court ordered ffices within your ment ant to s -367b(b) of the 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 . — For Court Use Only endorsed thereon, with the financial institution officer upon whom such demand was-made. ° Said sum shail 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 FI FICE OF THE CLERK one 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 SUPERIOR cau JRT 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 JUN 1 2 2015 from the receipt by you of such execution. of Hereof faijpot, and make due return of this writ with your doings thereon, according;to law. UDICI, AL DI STR ( Ci Se. (etles— re |" [> 1S __| OF LITCHFIELD Page 1 of 2 FINANCIAL INSTITUTION EXECUTION PROCEEDINGS lotNOTE: 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 41. If any funds 2 ‘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-CV-24a) and send, forthwith, 2 copies of both this form and the Exemption Claim 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. 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. electronic direct deposits that are feadily:identifiable. as exempt federal veterans’ benefits, Social security benefits, including, but not limited ‘to, retirement; ‘Survivors! and disability benefits, supplemental security. income benefits 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 thirty-day period preceding the date that the execution was served on you, you’shall leave the lesser of the account balance or one thousand dollars. in.the judgment.debtors’. account; provided nothing in this subsection shall be construed to limit your right, or obligation to remove such'funds from the debtor's account if required by any other provision of law or by @ court order. The judgment debtor shall have access to:such funds left in the judgment ebtor's account: You may notify the judgment creditor that funds ‘have been left in the .judgment debtors: 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-othef provision of state or federal law, of 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 tegard to the funds in the judgment debtor's account. 3. You must hold the: amount femoved fromthe judgment debtors account pursuant to: this executionfor fifteen days from the date you mail the copies ofthis formn 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. Ifyou 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:.éxecution and Exemption. Claim Form you must, upon demand, forthwith pay the serving officer the’ amount removed from the judgment debtor's account. 6. If no, exemption claim or secured party. claim noticé 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-ori the execution and you fail or refuse to da so, you-shall be liable:in an action therefor to. the: judgement’ creditor(s) named in the-execution for the-amount of nonexempt moriies which you fail or refuse: to pay. over. If no exemption claim is, filed 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 créditor(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. 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 éxempt monies. D-CV-26 (back/page 2) Rev: 12:09 Page 2 of 2EXEMPTION CLAIM FORM STATE OF CONNECTICUT FINANCIAL INSTITUTIOI ID-CV-24A, Rev, Ms TON EXECUTION SUPERIOR COURT ,_& C.G.S. 31-58()), 52-321, 62-350a, 52-362b, 62-3614, SEE INSTRUCTIONS ON BACKIPAGE 2 www,jud.ct.gov 52-387b, 29 U.S.C. 208(aX(1) : Y ‘Name and addréss of Judgment Debtor or Attorney (To be completed by judgment creditor or attomey) To. q MELISSA HICKCOX 1099 Hickory Hill Road Thomaston, Connecticut 06787 Section 1 — (To'be completed by judgment creditor) “judicial Housing Geooreplcal Name'and address of Cold (Nomber, Street; Town and Zip Code) Diva _O) session C1 Nitber LITCHPIELD-AT LiTCHEIELD, P.O. Box 247 Liichfiti. o6r6s ‘Name of case Name ofi Judgment Debtor~ ~ . “| Docket number. INIFUND CORPORATION v. MELISSA HICKGOX MELISSA Hickcox LLI-CV-14-6011202-5 ‘Section 2— (To be completed by financial institution - see instructions on back/page 2) [financial msiitulion to, whickvexemplion claim (i any)iso.be relumed ‘Dale‘ofmailing to Judgment Dabior “Test 4 Digits ofthe Account Number) ‘Amount rameved pursuant fo execution “Amountand lype of ready identifiable exenipl fands nol removed oO 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. 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 accounts) 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 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 forward 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 1, 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) {J Social Security. benefits (section 52-352b(g)) {JJ Private pension, trust, retirement, or medical savings {_] Unemployment benefits (section 52-352b(g)) account payments (sections 52-3214; 52-352b(m)) [_] Worker's Compensation benefits (section'52-352b(g)) (CJ Health or disability insurance payments (section 52-352b(e)) [J Veteran's benefits (section 52-352b(g)) [_] An amount in the bank riot to exceed $1000 (section 52-352b(r)) L_] Public Assistance payments (section 52-352b(d)) [2 Other claim of-exempt funds (Explain basis for claim of exemption): [] Wages* (section 52-361) oO Wages earned by a public assistance recipient under an incentive eamings or similar program (section 52-352b(d)) Amount claiméd to be exempt (CJ Court-ordered ‘child support payments (section 52-352b(h)) if less than the entire amount: LJ Alimony and support other than child support* (section 52-352b(n)) *See Note Regarding Exemption for Wages and Alimony on back/page 2. Signed Dale signed Telephone number “Complate mailing address of Judgment Deblor Subscribed and sworn Date At (Town) [Signed (Notary Public, Commissioner of Superior Court} to before me on * [ Page 1 of 2Instructions To.Financial Institution To Clerk 1. Complete section 2 of this form-and send:2 copies. 1. Attach this form to-each financial institution execution issued in a civil or of this form and the financiat institution execution family matter against a judgment debtor that is a natural person. form‘to the judgrient debtor and to. any secured 2. Deliver the execution along with this form tothe judgment creditor -Party that is party to a control agreement between requesting the execution. the'financial institution and such secured party 3. If judgment debtor completes and returns this form claiming an under article’ 9 of title 42a pursuant to'section : exemption, enter the appearance of the judgment-debtor with address. 52-367b of the General Statutes. set forth on page 1. \ If this claim of exemption is returned completed, fill ‘ Corte etn boone hearing. out section 4 of this form and mail,. within two. os + “ business days, to the issuing clerk’s office at the 6. Send fie stamped: Copy of this form to judgment debtor and judgment address of court indicated on the-front side. See 4 sa) inetit it additional instructions on the financial institution. 7. After hearing, send copy of any order entered to the financial institution. execution form. Nv 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 1esser of (1) twenty- five per cent-of the individual's disposable earnings 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. tit: 29, Section-206(a)(1), or (B); the state minimum hourly wage under subsection (j) of Section 31-58, in effect at the time the earnings.are payable. * toa * . - 8 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 earnings of amounts required to be withheld for payment of federal income.and employment taxes, normal retirement.contributions, union dues and initiation fees, grouip life insurance premiums, health insurance premiums and federal tax levies. - Section 5 — Proper Officer Must Complete This Section “Nate and tile of properofficer > > [ Dale oF service on tinandal institution: Telephone number Dale claim reckived. Date mailed to court "[-Name of nancial insttulion Section 6 — (To be completed by financial institution upon return of exemption claim form). Section 7 — Notice To Judgment Debtor And Judgment Creditor: " The assets in dispute are being held for (4 ) 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. © “ see . ‘ Dale or heating ‘Time of hearing ~ [Ta ‘Courtroom west if ED _ “ADA NOTICE ° The Judicial Branch’of the State of Connecticit 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. gow/ADA. Signed: (Assistant Clerk) ae Ba 7 ° "] Dale 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/Magistrate) . i. . . [7 sudge (1 Fsm LI Magistrate ianed: (dudge/Family Support Magisirate/Magistrate/Assistant Clerk)... .... _. bale signed ~~) be > ~ JD-CV-24A, (page 2) Rev, 4-13 Page 2 of 2