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FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT i lj i ll
PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT AS
WHO IS A NATURAL PERSON, www. jud.ct.gov .
APPLICATION AND EXECUTION (See page 2 for instructions to financial institution TE C ill
C.GS. §§ 52-356b, 52-367 and ADA Notice)
PA 14-7, 14-9 .
Instructions - Judgment Creditor Or Attorney Instructions - Clerk
4. Type or print legibly. 4. Check the file to ensure that the information provided
2. Complete the anpiication section; prepare original and 2 copies. ‘on the application is correct. X54790
3, Complete Section 4 of the Exémiption Claim Form, JD-CV-24a and attach to this form. 2. Sign original execution.
4, Prosont ariginal and 1 copy to clerk of court. Retain @ copy. 3, Retum original to applicant, retain a copy for file.
Address of court “Ra Jusicial district Geographic - | Docket number
50 FIELD ST TORRINGTON CT _0679)0) Housing session Co fimber_ LLI-CV14-6011160-8
Name and maiing address of Judgment Creditor or Atiomey (To be completed by Judgment Creditor)
rlaw Offices 4
Howard Lee Schiff,P.c.
P.O.Box 280245
E Hartford, CT 06108
“ne
Le 4
Nore OLAS PORDTNE “Ec
2 350 CAMINO DE LA REINA, SUITE 100, SAN DIEGO, CA 92108
§ | BHOETIDER “STN”
8 14 DRAPEAU RD NEW MILFORD, CT 06776 .
5 [A Rae Tso aaa
4. Total ‘amount BS (any) 6. Total amount anaig ery f Wm, hy G. Application fee for financial instep POR HG tated by te sour)
7. TR TBE BSE IG GETENS HTOTGTOR 8 ha cou ogre oajudamen cass ‘and fees STORaH Brssz aR
‘Check if applicable:
Is this judgment arising out of services rendered at a hospital? _| [ \pNo OO Yes [C1] postiudgment interest was ordered by the court
Weis a ucoment aca gt of servos rendered ata hospital, has a stay of a financial institution execution been Ng No [ves
Ifastay ofa inciat institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? ZERO PAID
[no Yes (Specify):
Siaffeg, (yaa
itor pr Ayorpey) Date signed Telephone nprper, _ =
(LIAL TI pear Asa-emtn TIAN 7 2020 W880) 528-9991
Financial Institution Execution °
To any proper officer,
‘Whereas on said Date of Judgment the above-named Judgment Créditor(s) recovered judgment against the above-named Jtidgment Debtor(s) before the above-
famed court for the arnourit of judgment, costs and fees stated above, as appears of record, whereof execution remains to be done. .
These ate, therefore, by autharity of the state of Connecticut to command you: . ah
‘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 couinty, upon an employee of such a branch office, such
‘employee and such branch office having been designated by the financial institution in accordance with reguiations adopted by the commissioner of banking, for
payment to you pursuant to section §2-367b(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, tagether.with the. *
attached affidavit and exemption claim form, with your doings endorsed theréon, 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 execistion per judgment debtor at a time, including copies thereof. Aftet 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 ora
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 -378b (c) of the General Statues (sixty days.or, with regard to federal benefits, such greater period as
Tequired by federal faw). If no 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 othenwise become unenfarceable.
Hereefail not,and make due return of this writ with your doings thereon, acgordjng to law.
Pagetof2 © FINANCIAL INSTITUTION EXECUTION PROCEEDING:
So) ‘has
Eg
1/06/20e on
NOTE: The provisions of section §2-367b, as amended from time to time, iake precedence over these instructions.
Instructions To Financial Institution Upon Receipt Of A Financial institution Execution
When Judgment Debtor Is A Natural Person
4. If any funds are removed from the judgment delstor’s account pursuant to subsection (c) of section 52-367b of the Gerieral Statutes,
complete section ll of the accompanying Exemption Claim Farm (JD-CV-24a) and (1) send, forthwith, 2 copies of both this form and the
Exemption Claim Form to the judgrnent debtor and to any secured party that is @ party to a control agreement between you and such
secured party under articie 9 of tile 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) rail notice to the judgment
debtor as required by 31CFR212.6 and 212.7.
Remove from the judgment dehtor’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 inierest and the Application’ Fee for Financial Institution Execution and other court
ordered postiudgment costs or feas 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 benefiis, 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 52-3526 of the Cannecticut General Statutes, or child support payments processed and received pursuant to Title IV-D of.
the Sociat 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 periad as required by federal iaw 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 shail 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 ta 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.
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if the judgment debtor retums the Exemption Claim Farm or other written natice 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 amoutit removed from the judgment debtor's account for forty-five days or until a couri order is received
tegarding 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 sécured parly claim notice to the clerk of the court, you must retum the funds to
the judgment debtor's account.
. IF you do not receive a claim of exemption or secured party claim notice within fifteerr days of the maifing to the judgment debtor and any
secured party of the execution and Exemption Claim Form you niust, upon demand, forthwith pay the serving officer the amount
removed from the judgment debtor's account.
g
a
. Hf 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 ot} the execution and you fail or refuse to do so, you shail be fiable in an
action therefor to the judgement creditor(s) named in the execution for the amoynt. of norexempt monies which you fail or refuse to pay
over, If no exemption claim is filed or if the court orders you ta pay the setving officer an amount removed from the judgment debtor's
account not exceeding the amount due on the execution and you fail or refuse to. de 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 fo one thousand dollars which you in. good faith allowed the judgment debtor to access pursuant to subsection (c) of section 52-367b
of thé General Statutes.
7. If you-pay exempt monies from the account of the judgment debtor contrary to these instructions, or the provisions of section $2-367b of
the General Statutes, you shall be fiable 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 exemp! monies so paid and you shal refund or waive
any charges of fees.by you, including. but not limited to, dishonored check fees, overdraft fees or minimum balaitce 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 af Connecticut complies with the Americans with
Disabilities Act (ADA). Hf you need a teasoniab!e accommodation in accordance with the
ADA, contact 2 court clerk or an ADA contact person listhd at waswjud.ct. gov/ADA,
JD-GV-24 (hack/page 2) Rev. 2-15 Page 2 of 2EXEMPTION CLAIM FORM @ @.... OF CONNECTICUT
FINANCIAL INSTITUTION EXECUTION SUPERIOR COURT
CGS. 31-58()), 52-3214, 52-380a, 62-362b, 52-361a, SEE INSTRUCTIONS ON BACK/PAGE 2 www.jud.ct.gov
52-367b, 29 U.S.C. 208(a)\1)
Name and adress of Judgment Debtor or Attorney
(To be comptoted by judgment creditor or attorney)
For court uso only
. T 7
To: MIXMPEX
| Jame
POL
BEI7TS
L J
Section 1 — (To be completed by judgment creditor)
1 Geographical ‘Name and address of Court (Number, Street, Town and Zip Code)
Judicfal Housing eee ee eee eee cosecg
yi Disvict __[C] session CJ Nuraber 50 FIELD SY TORRINGTON CT 04790
Name of case ‘Name of Judgment Debtor Docket number
MIDLAND FUND c R GINGH LLI-OUL 46011 260-8
ve BHUPINDER SINGH
Section 2 — (To be completed by financial institution - see instructions on back/page 2)
‘Name and address of financial institution to which exemption claim (if any) Is to be returned ‘Date of mailing to Judgment Debtor
Last 4 Digits of lhe Account Number(s) “Amount removed pursuant fo execution “Amount and type of readily identifiable exempt funds not removed
[J Additional sheet(s) attached hereto and made a part hereof (if necessary).
Section 3 — Notice To Judgment Debtor
As 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 récélvéd 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 field by the court to determine the issues raised by your claim.
SECTION 4 — AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW
|, the judgment debtor named above, claim and certify under the penalty of false statement that the money in the above account
is exempt by law from execution as follows: (“X" all that apply to the funds contained in this account)
(J Social Security benefits (section 52-352b(g)) (Z Private pension, trust, retirement, or medical savings
_ [-] Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, 52-352b(m))
[J Worker's Compensation benefits (section §2-352b(g)) (J Health or disability insurance payments (section 52-352b(e))
(J Veteran's benefits (section 52-352b(g)) (J) An amount in the bank not to exceed $1000 (section 52-352b(r))
[J Public Assistance payments (section 52-352b(d)). (J Other claim of exempt funds (Explain basis for claim of exemption):
{] Wages earned by a public assistance recipient under an
incentive earnings of similar program (section 52-352b(d)}
[J Court-ordered child support payments (section 52-352b(h)) Amount claimed to be exempt
(] 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 sworn Date At (Town). ‘Signed (Notary Public, Commissioner of Superior Court)
to before me on:
Page 1 of 2® e co
Instructions
To Financial institution To Clerk
1. Complete section.2.of this form and (1) send 2 copies 1. Attach this form to each financial institution execution issued in a civil or
of this form and the financial institution execution form family matter against a judgment debtor that is a natural person.
to the judgment debtor and to any secured party that is 2. Deliver the execution along with this form to the judgment creditor
party to a control agreement between the financial requesting the execution.
institution and such secured party under article 9 of 3. If judgment debtor completes and retums this form claiming an
title 42a pursuant to section 52-367b of the General exemption, enter the appearance of the judgment debtor with address
Statutes and (2) mail notice to judgment debtor as set forth on page 1.
required by 31CFR212.6 and 212.7. Set matter down for short calendar hearing.
If this claim of exemption is returned completed, fill out Complete section 7 below.
section 6 of this form and mail, within two business - Send file-stamped copy of this form to judgment debtor and judgment
days, to the issuing clerk's office at the address of creditor.
court indicated on the front side. See additional . After hearing, send copy of any order entered to the financial institution.
instructions on the financial institution execution form.
x
Oop
N
Note Regarding Exemption for Alimony and Support
Alimony and Suppott, other than child support, are exempt only to the following extent:
The amount of alimony and suppor, 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 earnings for that week, or (2) the amount by which the individual's
disposable earnings for that week exceed forty times the higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair
Labor Standards Act of 1938, U.S.C. 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 earnings are payable.
Section 52-350a(4) of the Connecticut General Statutes defines “disposable earnings" as that part of the earnings of an individual remaining
after the deduction from those eamings of amounts required to be withheld for payment of federal income and employment taxes, normal
retirement contributions, union dues and initiation fees, group life insurance premiums, health insurance premiums and federal tax levies:
Section 5 — Proper Officer Must Complete This Section
Name and tile of proper officer Date of service on financial institution, Telephone number
Section 6 — (To be completed by financial institution upon return of exemption claim form)
Date ciaim 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.
Date of hearing Time of hearing Ty] am. | couroom
Cl pm.
Signed (Assistant Clerk) Date signed
Order
The Court/Magistrate, having held a hearing to determine the issues raised by this claifn, hereby orders that:
By the Court (Name of Judge/Family Support Magistrate/Magistraie)
Cl] sudge 7] Fs [| Magistrate
‘Signed (Judge/Family Support Magistrate/Magistrate/Assistant Clerk) Daie signed
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). !f 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
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eos @ e FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT i lj i ll PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT AS WHO IS A NATURAL PERSON, www. jud.ct.gov . APPLICATION AND EXECUTION (See page 2 for instructions to financial institution TE C ill C.GS. §§ 52-356b, 52-367 and ADA Notice) PA 14-7, 14-9 . Instructions - Judgment Creditor Or Attorney Instructions - Clerk 4. Type or print legibly. 4. Check the file to ensure that the information provided 2. Complete the anpiication section; prepare original and 2 copies. ‘on the application is correct. X54790 3, Complete Section 4 of the Exémiption Claim Form, JD-CV-24a and attach to this form. 2. Sign original execution. 4, Prosont ariginal and 1 copy to clerk of court. Retain @ copy. 3, Retum original to applicant, retain a copy for file. Address of court “Ra Jusicial district Geographic - | Docket number 50 FIELD ST TORRINGTON CT _0679)0) Housing session Co fimber_ LLI-CV14-6011160-8 Name and maiing address of Judgment Creditor or Atiomey (To be completed by Judgment Creditor) rlaw Offices 4 Howard Lee Schiff,P.c. P.O.Box 280245 E Hartford, CT 06108 “ne Le 4 Nore OLAS PORDTNE “Ec 2 350 CAMINO DE LA REINA, SUITE 100, SAN DIEGO, CA 92108 § | BHOETIDER “STN” 8 14 DRAPEAU RD NEW MILFORD, CT 06776 . 5 [A Rae Tso aaa 4. Total ‘amount BS (any) 6. Total amount anaig ery f Wm, hy G. Application fee for financial instep POR HG tated by te sour) 7. TR TBE BSE IG GETENS HTOTGTOR 8 ha cou ogre oajudamen cass ‘and fees STORaH Brssz aR ‘Check if applicable: Is this judgment arising out of services rendered at a hospital? _| [ \pNo OO Yes [C1] postiudgment interest was ordered by the court Weis a ucoment aca gt of servos rendered ata hospital, has a stay of a financial institution execution been Ng No [ves Ifastay ofa inciat institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? ZERO PAID [no Yes (Specify): Siaffeg, (yaa itor pr Ayorpey) Date signed Telephone nprper, _ = (LIAL TI pear Asa-emtn TIAN 7 2020 W880) 528-9991 Financial Institution Execution ° To any proper officer, ‘Whereas on said Date of Judgment the above-named Judgment Créditor(s) recovered judgment against the above-named Jtidgment Debtor(s) before the above- famed court for the arnourit of judgment, costs and fees stated above, as appears of record, whereof execution remains to be done. . These ate, therefore, by autharity of the state of Connecticut to command you: . ah ‘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 couinty, upon an employee of such a branch office, such ‘employee and such branch office having been designated by the financial institution in accordance with reguiations adopted by the commissioner of banking, for payment to you pursuant to section §2-367b(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, tagether.with the. * attached affidavit and exemption claim form, with your doings endorsed theréon, 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 execistion per judgment debtor at a time, including copies thereof. Aftet 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 ora 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 -378b (c) of the General Statues (sixty days.or, with regard to federal benefits, such greater period as Tequired by federal faw). If no 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 othenwise become unenfarceable. Hereefail not,and make due return of this writ with your doings thereon, acgordjng to law. Pagetof2 © FINANCIAL INSTITUTION EXECUTION PROCEEDING: So) ‘has Eg 1/06/20e on NOTE: The provisions of section §2-367b, as amended from time to time, iake precedence over these instructions. Instructions To Financial Institution Upon Receipt Of A Financial institution Execution When Judgment Debtor Is A Natural Person 4. If any funds are removed from the judgment delstor’s account pursuant to subsection (c) of section 52-367b of the Gerieral Statutes, complete section ll of the accompanying Exemption Claim Farm (JD-CV-24a) and (1) send, forthwith, 2 copies of both this form and the Exemption Claim Form to the judgrnent debtor and to any secured party that is @ party to a control agreement between you and such secured party under articie 9 of tile 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) rail notice to the judgment debtor as required by 31CFR212.6 and 212.7. Remove from the judgment dehtor’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 inierest and the Application’ Fee for Financial Institution Execution and other court ordered postiudgment costs or feas 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 benefiis, 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 52-3526 of the Cannecticut General Statutes, or child support payments processed and received pursuant to Title IV-D of. the Sociat 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 periad as required by federal iaw 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 shail 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 ta 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. N > if the judgment debtor retums the Exemption Claim Farm or other written natice 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 amoutit removed from the judgment debtor's account for forty-five days or until a couri order is received tegarding 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 sécured parly claim notice to the clerk of the court, you must retum the funds to the judgment debtor's account. . IF you do not receive a claim of exemption or secured party claim notice within fifteerr days of the maifing to the judgment debtor and any secured party of the execution and Exemption Claim Form you niust, upon demand, forthwith pay the serving officer the amount removed from the judgment debtor's account. g a . Hf 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 ot} the execution and you fail or refuse to do so, you shail be fiable in an action therefor to the judgement creditor(s) named in the execution for the amoynt. of norexempt monies which you fail or refuse to pay over, If no exemption claim is filed or if the court orders you ta pay the setving officer an amount removed from the judgment debtor's account not exceeding the amount due on the execution and you fail or refuse to. de 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 fo one thousand dollars which you in. good faith allowed the judgment debtor to access pursuant to subsection (c) of section 52-367b of thé General Statutes. 7. If you-pay exempt monies from the account of the judgment debtor contrary to these instructions, or the provisions of section $2-367b of the General Statutes, you shall be fiable 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 exemp! monies so paid and you shal refund or waive any charges of fees.by you, including. but not limited to, dishonored check fees, overdraft fees or minimum balaitce 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 af Connecticut complies with the Americans with Disabilities Act (ADA). Hf you need a teasoniab!e accommodation in accordance with the ADA, contact 2 court clerk or an ADA contact person listhd at waswjud.ct. gov/ADA, JD-GV-24 (hack/page 2) Rev. 2-15 Page 2 of 2EXEMPTION CLAIM FORM @ @.... OF CONNECTICUT FINANCIAL INSTITUTION EXECUTION SUPERIOR COURT CGS. 31-58()), 52-3214, 52-380a, 62-362b, 52-361a, SEE INSTRUCTIONS ON BACK/PAGE 2 www.jud.ct.gov 52-367b, 29 U.S.C. 208(a)\1) Name and adress of Judgment Debtor or Attorney (To be comptoted by judgment creditor or attorney) For court uso only . T 7 To: MIXMPEX | Jame POL BEI7TS L J Section 1 — (To be completed by judgment creditor) 1 Geographical ‘Name and address of Court (Number, Street, Town and Zip Code) Judicfal Housing eee ee eee eee cosecg yi Disvict __[C] session CJ Nuraber 50 FIELD SY TORRINGTON CT 04790 Name of case ‘Name of Judgment Debtor Docket number MIDLAND FUND c R GINGH LLI-OUL 46011 260-8 ve BHUPINDER SINGH Section 2 — (To be completed by financial institution - see instructions on back/page 2) ‘Name and address of financial institution to which exemption claim (if any) Is to be returned ‘Date of mailing to Judgment Debtor Last 4 Digits of lhe Account Number(s) “Amount removed pursuant fo execution “Amount and type of readily identifiable exempt funds not removed [J Additional sheet(s) attached hereto and made a part hereof (if necessary). Section 3 — Notice To Judgment Debtor As 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 récélvéd 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 field by the court to determine the issues raised by your claim. SECTION 4 — AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW |, the judgment debtor named above, claim and certify under the penalty of false statement that the money in the above account is exempt by law from execution as follows: (“X" all that apply to the funds contained in this account) (J Social Security benefits (section 52-352b(g)) (Z Private pension, trust, retirement, or medical savings _ [-] Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, 52-352b(m)) [J Worker's Compensation benefits (section §2-352b(g)) (J Health or disability insurance payments (section 52-352b(e)) (J Veteran's benefits (section 52-352b(g)) (J) An amount in the bank not to exceed $1000 (section 52-352b(r)) [J Public Assistance payments (section 52-352b(d)). (J Other claim of exempt funds (Explain basis for claim of exemption): {] Wages earned by a public assistance recipient under an incentive earnings of similar program (section 52-352b(d)} [J Court-ordered child support payments (section 52-352b(h)) Amount claimed to be exempt (] 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 sworn Date At (Town). ‘Signed (Notary Public, Commissioner of Superior Court) to before me on: Page 1 of 2® e co Instructions To Financial institution To Clerk 1. Complete section.2.of this form and (1) send 2 copies 1. Attach this form to each financial institution execution issued in a civil or of this form and the financial institution execution form family matter against a judgment debtor that is a natural person. to the judgment debtor and to any secured party that is 2. Deliver the execution along with this form to the judgment creditor party to a control agreement between the financial requesting the execution. institution and such secured party under article 9 of 3. If judgment debtor completes and retums this form claiming an title 42a pursuant to section 52-367b of the General exemption, enter the appearance of the judgment debtor with address Statutes and (2) mail notice to judgment debtor as set forth on page 1. required by 31CFR212.6 and 212.7. Set matter down for short calendar hearing. If this claim of exemption is returned completed, fill out Complete section 7 below. section 6 of this form and mail, within two business - Send file-stamped copy of this form to judgment debtor and judgment days, to the issuing clerk's office at the address of creditor. court indicated on the front side. See additional . After hearing, send copy of any order entered to the financial institution. instructions on the financial institution execution form. x Oop N Note Regarding Exemption for Alimony and Support Alimony and Suppott, other than child support, are exempt only to the following extent: The amount of alimony and suppor, 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 earnings for that week, or (2) the amount by which the individual's disposable earnings for that week exceed forty times the higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair Labor Standards Act of 1938, U.S.C. 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 earnings are payable. Section 52-350a(4) of the Connecticut General Statutes defines “disposable earnings" as that part of the earnings of an individual remaining after the deduction from those eamings of amounts required to be withheld for payment of federal income and employment taxes, normal retirement contributions, union dues and initiation fees, group life insurance premiums, health insurance premiums and federal tax levies: Section 5 — Proper Officer Must Complete This Section Name and tile of proper officer Date of service on financial institution, Telephone number Section 6 — (To be completed by financial institution upon return of exemption claim form) Date ciaim 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. Date of hearing Time of hearing Ty] am. | couroom Cl pm. Signed (Assistant Clerk) Date signed Order The Court/Magistrate, having held a hearing to determine the issues raised by this claifn, hereby orders that: By the Court (Name of Judge/Family Support Magistrate/Magistraie) Cl] sudge 7] Fs [| Magistrate ‘Signed (Judge/Family Support Magistrate/Magistrate/Assistant Clerk) Daie signed ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). !f 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