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FINANCIAL INSTITUTION EXECUTION PROCEEDINGS STATE OF CONNECTICUT
JUDGMENT DEBTOR WHO:IS A NATURAL PERSON, SUPERIOR COURT oH
APPLICATION AND EXECUTION www.jud.ct.gov ee
JD-CV-24 Re 14-2
C.G.S. §§ 52-356b, 52-367b (See page 2 for instructions to financial institution and ADA Notice)
Instructions - Judgment Creditor or Attorney Instructions - Clerk
1. Complete this form, an Exemption Claim form, and a Finaricial institution Execution (form JO-CV-24A). 1. Check the file {0 ensure the information on the application is correct.
If filing electronically, combine into one POF document. If filing on paper, prepare original, attach form 2. Sign original execution,
JD-CV-24A and file the original with the clerk. Keep 1 copy for your records.
2 Applications must be accompanied by the statutory fee set in General Statutes § 52-367b. 3. Upload the original to the file.
‘Address of court EX] Judicial District Docket number
50 FIELD STREET TORRINGTON CT 06790 J Housing Session | LLI-CV-21-6028430-S
‘Name and mailing address of Judgment Creditor or Attorney
(Number, sireet, town, state, zip code) (To be completed by Judgment Creditor) (Plaintif)
COURT USE ONLY
MIDLAND CREDIT MANAGEMENT, INC APFEABA EXISSUE
C/O London
48 Christian
& London
Lane Newington, CT 06111
il CULO ttl tl it iil
L + 21-11342
Name(s) and address(es) of Judgment Creditor(s) (Party fo whom money is owed) (Number, street, town, zip code)
C/O London & London, 48 Christian Lane
MIDLAND CREDIT MANAGEMENT, INC
Newington, CT 06111
2 Name(s) and address(es) of Judgment Debtor(s) (Parly who owes money) (Number, street, town, Zip code)
Kayla Beyus
179 Pearl St Apt 1
2
Torrington CT 06790-5232
Bate of judgment T. Amount of judgment (include, where applicable, | 2. Amount of costs and fees 3. Total amount of judgment, costs and fees (Add 7 and 2)
09/23/2021 1,117.04 prejudgment interest and 102.40 1,219.44
attorney's fees)
F Totalamount paid (any) 5.Total amount unpaid (Subtract 4 from 3) 6. Application fee for financial institution execution (if not waived by te court)
0.00 1219.44 105.00
T. Application fees paid for prior executions on this judgment . Other court ordered postjudgment costs and fees Total oftems 5, 6, 7 and 6
105.00 0.00 1,429.44
Is this judgment arising out of services rendered at a hospital?. TX] No O Yes Select applicable:
Postjudgment interest was
If yes above, has a stay of a financial institution execution been
_ EX]No OO Yes
a ordered by the court
enitered pursuant to an installment payment order? .
If a stay of a financial institution execution has been entered, has the
Judgment Debtor defaulted on an installment payment order? [No IX] Yes (Specity)
weekly Payments of 35.00 beginning on 10/22/2021
‘Signed (Judgment Creditor or Attorney) (Party to whom money is owed) Date signed Telephone number
400805 Russell L. London 08/10/2023 860-666-4500
Financial Institution Execution
To any proper officer,
By authority of the State of Connecticut, and pursuant ‘to General Statutes § 52-367b you are ordered as follows: Within 7 days, make demand for
payment to you of any nonexempt debt owed by the Judgment Debtor(s). Make this demand upon the main office of any financial institution having
its main office within your county. If the main office is not within your county, but a branch office of the institution is within your county, make
demand on an employee of such branch office as long the emplayee and the branch office have been designated by the financial institution in
accordance with regulations adopted by the commissioner of banking. Only upon demand of a financial institution which does not have any main
office or branch office in this state, demand may be made by certified mail, return receipt requested.
After having made demand you are directed to serve a true and attested copy of this execution, together with the attached affidavit and Exemption
Claim form, Financial Execution (form JD-CV-24A), with your doings endorsed thereon, upon the financial institution officer upon whom the demand
was made. Receive the sum paid by the financial institution and apply it on this execution in accordance with the provisions of General Statutes §
§2-367b.
Do not serve more than one financial institution execution per Judgment Debtor at a time, including copies
After service of an execution on one financial institution, do not serve the same execution of a copy on anather For Court Use Only
financial institution until receiving confirmation from the preceding financial institution that the Judgment
Debtor had insufficient funds available for collection to satisfy the execution. However, any additional service
of an execution must not be made later than 45 days from your initial receipt of the execution.
Also, after service of an execution, do not serve the same execution or a copy on the financial institution if an
electronic direct deposit from a readily identifiable source described in General Statutes § 52-376b (c) was
made to the Judgment Debtor's account within the look-back period described in General Statutes § 52-376b
(c) (2 months or, with regard to federal benefits, such greater periad as required by federal law). Ifno such
deposit was made, you may subsequently serve the same execution if 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 Clerk) Date signed
M/w/Ix5
Page 1 of 2
21-11342
NOTE: The provisions of General Statules § 52-367b, as amended, 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 General Statutes § 52-367b(c), complete
section Il of the attached-Exemption Claim Form, Financial Institution Execution (form JD-CV-24A) and take the following
actions: (1) Send 2 copies of both this form and the Exemption Claim Form, Financial Institution Execution form to the
Judgment Debtor and any secured party that is a party to a control agreement between you and the secured party under
article 9 of title 42a of the General Statutes. Copies must be sent postage pre-paid, to the last known address in your
records of the recipient; and (2) Issue nolice lo the account holder, or to a fiduciary who administers the account and
receives communications on behalf of the.account holder, in the time and manner stated in Federal Regulations
31 CFR 212.6 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 included in’box 9 of the application on page 1 of this form, plus postjudgment interest, if ordered by the
court, and the serving officer's fee. You must take this action before your midnight deadline, as defined in General Statutes
§ 42a-4-104,
Leave in the Judgment Debtor's account (A) the full amount of electronic direct deposits that are readily identifiable as
exempt federal veterans’ benefits, Social Security benefits, including, but not limited to, retirement, survivors’ and disability
benefits, supplemental security income benefits, exempt benefits paid by the federal Railroad Retirement Board or the
federal Office of Personnel Management, unemployment compensation benefits exempt under General Statutes § 52-352b
child support payments processed and received pursuant to Title IV-D of the Social Security Acl, and (B) the amount of the
electronic direct deposits, not to exceed $1,000, that are readily identifiable as wages provided such deposits were made to
the account during the look-back period of two months preceding the date that the execution was served on the financial
institution, or, with regard to federal benefits, such greater time as required by federal law. If no such deposits have been
made to the Judgment Debtor's account during the look-back period, or if such readily identifiable funds are less than
$1,000, leave in the account as exempt pursuant to General Statutes § 52-352b(18), the lesser of the account balance or
$1,000 in the aggregate. To the extent that such funds are left in the account as exempt pursuant to General Statutes §
52-352b(18), the provisions of that section shall not be the basis for a claim of exemption pursuant to this section in
response lo a levy of execution. However, nothing in this paragraph shall be construed to limil 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 any funds left in the account. You may notify the Judgment
Creditor that funds have been left in the Judgment Debtor's account pursuant to this provision. Also, nothing in this
paragraph shall alter the exempt status of funds which are exempt from execution under Generai Statutes § 52-367b(a) or
under any other provision of state or federal law, or the right of a Judgment Debtor to claim such exemption, Further,
nothing in this paragraph 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,
Hold the amount removed from the Judgment Debtor's account pursuant to this execution for 15 days from the date you
mail the copies of this form and the Exemption Claim Form, Financial Institution Execution form to the Judgment Debtor
and-any secured party. During the 15 day period you must not pay the officer serving this execution.
If the Judgment Debtor returns the Exemption Claim Form, Financial Institution Execution form or other written notice that
an exemption is.being claimed ar if any secured party delivers to you written notice of their claim of a prior perfected
security interest in the account, you must, within 2 business days of receipt of such nolice, send a copy of such nolice to
the clerk of the court that issued the execution. Continue fo hold the amount removed from the Judgment Debtor's account
for 45 days of until you receive a court order regarding disposition of the funds, whichever occurs first. If no order is
received within 45 days of the date you send a copy of the Exemption Claim Form, Financial Institution Execution form or
notice of exemption or a secured party claim’notice to the clerk of the court, return the funds to the Judgment Debtor's
account.
If you do not receive the Exemption Claim Form, Financial Institution Execution form or secured party claim notice within 15
days of mailing the required documents to the Judgment Debtor and any secured parly, you must, upon demand, pay the
serving officer the amount removed from the Judgment Debtor's account.
If no Exemption Claim Form, Financial institution Execution form 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 to the Judgement Creditor(s) named in the
execution for the amount of nonexempt monies which you fail or refuse ta pay, excluding funds of up to $1,000 which you
in good faith allowed the Judgment Debtor to access pursuant to General Statutes § 92-367b(c).
If you pay exempt monies from the account of the Judgment Debtor contrary to these instructions, or the provisions of
General Statutes § 52-367b, you shall be liable in an action to the Judgment Debtor for any exempt monies paid and you
shall refund or waive any charges of fees by you, including, but not limited to, dishonored check fees, overdraft or minimum
balance service charges and legal process fees, which were assessed as a result of such payment of exempt monies.
—
For information on ADA accommodations,
contact a court clerk or go to: www.jud.ct.gow/ADA.
JO-CV-26 Rov. 11-21 Page 2 of 2
BO
EXEMPTION CLAIM FORM STATE OF CONNECTICUT, S aay.
FINANCIAL INSTITUTION EXECUTION SUPERIOR COURT
JD-CV24A Rov. 10-21 aww jud.ct.gov
O.GS, §§ 31-58), 52-321a, $2-350a, 52.382, 62.361, SEE INSTRUCTIONS ON BACK/PAGE 2 Gee
52-367; 29US.C. 206(a)(1)
Name and address of Judgment Debtor oF Attomey
(To ba completed by judgment creditor
or attomey) COURT USE ONLY|
MXMPEX
To: "Kayla Beyus
ARICA
179 Pearl St Apt 1
Torrington CT 06790-5232 J 21-11342
Section 1 - (To be completed by judgment creditor) €
Judicial Housing Name and address of Coun (Aidmbar, Sireat, Town and Zip Codey
&l District Session SUPERIOR COURT 50 FIELD STREET TORRINGTON CT 06790
Name of e@seyiDL
AND CREDIT MANAGEMENT, INC Nama of Judgment Debtor ackal numer
Kayla Beyus
, Kayla Beyus LLI-CV-21-6028430-S
Section 2 - (To be completed by financial institution - see instructions on back/page 2)
Name and address of financial Inetitution to whiichi exempilon claim (if any) 16 to be retumed Baie of mailing te Judgment Debtor
Tast Digitsaf the Account Number(s) “Rmnount pamaved pursuant to exacuion “Amount and type of axempl finds not removed
O Additional sheet(s) attached hereto and made a part hereof (if necessary).
Section 3 - Notice to Judgment Debtor
As aresult 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 sel-forth below.
HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW. If you wish to claim that the money removed from your account(s) pursuant
to this execution 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
creditar of the dale 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: (select all that apply to the funds contained in this account)
(2 Social Security benefits (section 52-352b(7)) ( Private pension, trust, retirement, or medical savings account
(CJ unempioyment benefits (section 52-352b(7)) payments (sections 52-3214, 52-352b(13))
(J Worker's Compensation benefits (section 52-352b(7)) (1) Health or disability insurance payments (section 52-352b(5))
C) Veteran's benefits (section 52-352b(7)) (CJ Other claim of exempt funds (Explain casis
for claim of exemption):
CZ Public Assistance payments (section 52-352b(4))
(_] Wages eamed by a public assistance recipient under an
incentive eamings or similar program (section 52-352b(4))
C2 Court-erdered child support payments (section 52-352b(8)) Amount claimed to be exempt
(J) Alimony and support other than child support” (section 52-352(14)) if less than the entire smount:
*See Note Regarding Exemption for Almany and Suppart on back/page 2.
‘Signed Bate signed ‘Telopirone number
‘Compieie maiing address of Judgment Debior
Subscribed and swom Baie At (Fowny Signed (Notary Public. Commissioncr of Supcrios Court}
Jo before me‘on ; ——=
an
Page 1 of 2
Instructions 21-11342
To Financial Institution To Clerk
4 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 returns this form claiming an exemption,
title 42a pursuant to General Statutes § 52-367b and
enter the appearance of the judgment debtor with address set forth on
(2) mail notice to judgment dehtor as required by
page 1.
31CFR212.6 and 212.7.
Set matter down for hearing.
If this claim of exemption is retumed completed, fill out Complete Section 7 below.
Section 6 of this form and mail, within two business.
Send fite-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
instructions on the financial institution execution form. After hearing, send copy of any order entered to the financial institution.
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 earnings for that week, or (2) the amount by which the individual's
disposable earnings for that week exceed forty timas the higher af (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.
General Statutes § 52-350a(4) defines “disposable earnings"as that part of the earnings 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, group life insurance premiums, health insurance premiums and federal tax levies.
Section 5 - Proper Officer Must Complete this Section
Name and tite of propar officer Date of service on financial institution Telephone number
Section 6 - (To be completed by financial institution upon return of exemption claim form)
Date claim received Date mailed to court Name of financial institation Telephone number
Section 7 - Notice to Judgment Debtor and Judgment Creditor
The money removed from your account(s) pursuant to this execution is 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 on the date set forth below, whichever occurs earlier.
Baie of hearing Tino of hearing Cam. ‘Courtroom
[i p.m.
Signed (Assistant Clerk) Date signed
Order :
The CourtMagistrate, having held a hearing to determine the issues raised by this claim, hereby orders that:
By the Court (Name of JudgeFunily Support Magistralemagistratey
[TJ Judge ( rsu CC] Magistrate
‘Signed (ludge/Family Srippart Magistrate/Magistcate/Assistant Clerk) Date signed
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable
accommodation vin accordance with the ADA. contact a courl clerk or an ADA contact person listed al wwwjud.cl.gov/ADA.
oe —
D-CV-24A (page 2) Rav. 10-24 Page
2 of 2
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a FINANCIAL INSTITUTION EXECUTION PROCEEDINGS STATE OF CONNECTICUT JUDGMENT DEBTOR WHO:IS A NATURAL PERSON, SUPERIOR COURT oH APPLICATION AND EXECUTION www.jud.ct.gov ee JD-CV-24 Re 14-2 C.G.S. §§ 52-356b, 52-367b (See page 2 for instructions to financial institution and ADA Notice) Instructions - Judgment Creditor or Attorney Instructions - Clerk 1. Complete this form, an Exemption Claim form, and a Finaricial institution Execution (form JO-CV-24A). 1. Check the file {0 ensure the information on the application is correct. If filing electronically, combine into one POF document. If filing on paper, prepare original, attach form 2. Sign original execution, JD-CV-24A and file the original with the clerk. Keep 1 copy for your records. 2 Applications must be accompanied by the statutory fee set in General Statutes § 52-367b. 3. Upload the original to the file. ‘Address of court EX] Judicial District Docket number 50 FIELD STREET TORRINGTON CT 06790 J Housing Session | LLI-CV-21-6028430-S ‘Name and mailing address of Judgment Creditor or Attorney (Number, sireet, town, state, zip code) (To be completed by Judgment Creditor) (Plaintif) COURT USE ONLY MIDLAND CREDIT MANAGEMENT, INC APFEABA EXISSUE C/O London 48 Christian & London Lane Newington, CT 06111 il CULO ttl tl it iil L + 21-11342 Name(s) and address(es) of Judgment Creditor(s) (Party fo whom money is owed) (Number, street, town, zip code) C/O London & London, 48 Christian Lane MIDLAND CREDIT MANAGEMENT, INC Newington, CT 06111 2 Name(s) and address(es) of Judgment Debtor(s) (Parly who owes money) (Number, street, town, Zip code) Kayla Beyus 179 Pearl St Apt 1 2 Torrington CT 06790-5232 Bate of judgment T. Amount of judgment (include, where applicable, | 2. Amount of costs and fees 3. Total amount of judgment, costs and fees (Add 7 and 2) 09/23/2021 1,117.04 prejudgment interest and 102.40 1,219.44 attorney's fees) F Totalamount paid (any) 5.Total amount unpaid (Subtract 4 from 3) 6. Application fee for financial institution execution (if not waived by te court) 0.00 1219.44 105.00 T. Application fees paid for prior executions on this judgment . Other court ordered postjudgment costs and fees Total oftems 5, 6, 7 and 6 105.00 0.00 1,429.44 Is this judgment arising out of services rendered at a hospital?. TX] No O Yes Select applicable: Postjudgment interest was If yes above, has a stay of a financial institution execution been _ EX]No OO Yes a ordered by the court enitered pursuant to an installment payment order? . If a stay of a financial institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? [No IX] Yes (Specity) weekly Payments of 35.00 beginning on 10/22/2021 ‘Signed (Judgment Creditor or Attorney) (Party to whom money is owed) Date signed Telephone number 400805 Russell L. London 08/10/2023 860-666-4500 Financial Institution Execution To any proper officer, By authority of the State of Connecticut, and pursuant ‘to General Statutes § 52-367b you are ordered as follows: Within 7 days, make demand for payment to you of any nonexempt debt owed by the Judgment Debtor(s). Make this demand upon the main office of any financial institution having its main office within your county. If the main office is not within your county, but a branch office of the institution is within your county, make demand on an employee of such branch office as long the emplayee and the branch office have been designated by the financial institution in accordance with regulations adopted by the commissioner of banking. Only upon demand of a financial institution which does not have any main office or branch office in this state, demand may be made by certified mail, return receipt requested. After having made demand you are directed to serve a true and attested copy of this execution, together with the attached affidavit and Exemption Claim form, Financial Execution (form JD-CV-24A), with your doings endorsed thereon, upon the financial institution officer upon whom the demand was made. Receive the sum paid by the financial institution and apply it on this execution in accordance with the provisions of General Statutes § §2-367b. Do not serve more than one financial institution execution per Judgment Debtor at a time, including copies After service of an execution on one financial institution, do not serve the same execution of a copy on anather For Court Use Only financial institution until receiving confirmation from the preceding financial institution that the Judgment Debtor had insufficient funds available for collection to satisfy the execution. However, any additional service of an execution must not be made later than 45 days from your initial receipt of the execution. Also, after service of an execution, do not serve the same execution or a copy on the financial institution if an electronic direct deposit from a readily identifiable source described in General Statutes § 52-376b (c) was made to the Judgment Debtor's account within the look-back period described in General Statutes § 52-376b (c) (2 months or, with regard to federal benefits, such greater periad as required by federal law). Ifno such deposit was made, you may subsequently serve the same execution if 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 Clerk) Date signed M/w/Ix5 Page 1 of 2 21-11342 NOTE: The provisions of General Statules § 52-367b, as amended, 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 General Statutes § 52-367b(c), complete section Il of the attached-Exemption Claim Form, Financial Institution Execution (form JD-CV-24A) and take the following actions: (1) Send 2 copies of both this form and the Exemption Claim Form, Financial Institution Execution form to the Judgment Debtor and any secured party that is a party to a control agreement between you and the secured party under article 9 of title 42a of the General Statutes. Copies must be sent postage pre-paid, to the last known address in your records of the recipient; and (2) Issue nolice lo the account holder, or to a fiduciary who administers the account and receives communications on behalf of the.account holder, in the time and manner stated in Federal Regulations 31 CFR 212.6 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 included in’box 9 of the application on page 1 of this form, plus postjudgment interest, if ordered by the court, and the serving officer's fee. You must take this action before your midnight deadline, as defined in General Statutes § 42a-4-104, Leave in the Judgment Debtor's account (A) the full amount of electronic direct deposits that are readily identifiable as exempt federal veterans’ benefits, Social Security benefits, including, but not limited to, retirement, survivors’ and disability benefits, supplemental security income benefits, exempt benefits paid by the federal Railroad Retirement Board or the federal Office of Personnel Management, unemployment compensation benefits exempt under General Statutes § 52-352b child support payments processed and received pursuant to Title IV-D of the Social Security Acl, and (B) the amount of the electronic direct deposits, not to exceed $1,000, that are readily identifiable as wages provided such deposits were made to the account during the look-back period of two months preceding the date that the execution was served on the financial institution, or, with regard to federal benefits, such greater time as required by federal law. If no such deposits have been made to the Judgment Debtor's account during the look-back period, or if such readily identifiable funds are less than $1,000, leave in the account as exempt pursuant to General Statutes § 52-352b(18), the lesser of the account balance or $1,000 in the aggregate. To the extent that such funds are left in the account as exempt pursuant to General Statutes § 52-352b(18), the provisions of that section shall not be the basis for a claim of exemption pursuant to this section in response lo a levy of execution. However, nothing in this paragraph shall be construed to limil 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 any funds left in the account. You may notify the Judgment Creditor that funds have been left in the Judgment Debtor's account pursuant to this provision. Also, nothing in this paragraph shall alter the exempt status of funds which are exempt from execution under Generai Statutes § 52-367b(a) or under any other provision of state or federal law, or the right of a Judgment Debtor to claim such exemption, Further, nothing in this paragraph 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, Hold the amount removed from the Judgment Debtor's account pursuant to this execution for 15 days from the date you mail the copies of this form and the Exemption Claim Form, Financial Institution Execution form to the Judgment Debtor and-any secured party. During the 15 day period you must not pay the officer serving this execution. If the Judgment Debtor returns the Exemption Claim Form, Financial Institution Execution form or other written notice that an exemption is.being claimed ar if any secured party delivers to you written notice of their claim of a prior perfected security interest in the account, you must, within 2 business days of receipt of such nolice, send a copy of such nolice to the clerk of the court that issued the execution. Continue fo hold the amount removed from the Judgment Debtor's account for 45 days of until you receive a court order regarding disposition of the funds, whichever occurs first. If no order is received within 45 days of the date you send a copy of the Exemption Claim Form, Financial Institution Execution form or notice of exemption or a secured party claim’notice to the clerk of the court, return the funds to the Judgment Debtor's account. If you do not receive the Exemption Claim Form, Financial Institution Execution form or secured party claim notice within 15 days of mailing the required documents to the Judgment Debtor and any secured parly, you must, upon demand, pay the serving officer the amount removed from the Judgment Debtor's account. If no Exemption Claim Form, Financial institution Execution form 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 to the Judgement Creditor(s) named in the execution for the amount of nonexempt monies which you fail or refuse ta pay, excluding funds of up to $1,000 which you in good faith allowed the Judgment Debtor to access pursuant to General Statutes § 92-367b(c). If you pay exempt monies from the account of the Judgment Debtor contrary to these instructions, or the provisions of General Statutes § 52-367b, you shall be liable in an action to the Judgment Debtor for any exempt monies paid and you shall refund or waive any charges of fees by you, including, but not limited to, dishonored check fees, overdraft or minimum balance service charges and legal process fees, which were assessed as a result of such payment of exempt monies. — For information on ADA accommodations, contact a court clerk or go to: www.jud.ct.gow/ADA. JO-CV-26 Rov. 11-21 Page 2 of 2 BO EXEMPTION CLAIM FORM STATE OF CONNECTICUT, S aay. FINANCIAL INSTITUTION EXECUTION SUPERIOR COURT JD-CV24A Rov. 10-21 aww jud.ct.gov O.GS, §§ 31-58), 52-321a, $2-350a, 52.382, 62.361, SEE INSTRUCTIONS ON BACK/PAGE 2 Gee 52-367; 29US.C. 206(a)(1) Name and address of Judgment Debtor oF Attomey (To ba completed by judgment creditor or attomey) COURT USE ONLY| MXMPEX To: "Kayla Beyus ARICA 179 Pearl St Apt 1 Torrington CT 06790-5232 J 21-11342 Section 1 - (To be completed by judgment creditor) € Judicial Housing Name and address of Coun (Aidmbar, Sireat, Town and Zip Codey &l District Session SUPERIOR COURT 50 FIELD STREET TORRINGTON CT 06790 Name of e@seyiDL AND CREDIT MANAGEMENT, INC Nama of Judgment Debtor ackal numer Kayla Beyus , Kayla Beyus LLI-CV-21-6028430-S Section 2 - (To be completed by financial institution - see instructions on back/page 2) Name and address of financial Inetitution to whiichi exempilon claim (if any) 16 to be retumed Baie of mailing te Judgment Debtor Tast Digitsaf the Account Number(s) “Rmnount pamaved pursuant to exacuion “Amount and type of axempl finds not removed O Additional sheet(s) attached hereto and made a part hereof (if necessary). Section 3 - Notice to Judgment Debtor As aresult 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 sel-forth below. HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW. If you wish to claim that the money removed from your account(s) pursuant to this execution 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 creditar of the dale 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: (select all that apply to the funds contained in this account) (2 Social Security benefits (section 52-352b(7)) ( Private pension, trust, retirement, or medical savings account (CJ unempioyment benefits (section 52-352b(7)) payments (sections 52-3214, 52-352b(13)) (J Worker's Compensation benefits (section 52-352b(7)) (1) Health or disability insurance payments (section 52-352b(5)) C) Veteran's benefits (section 52-352b(7)) (CJ Other claim of exempt funds (Explain casis for claim of exemption): CZ Public Assistance payments (section 52-352b(4)) (_] Wages eamed by a public assistance recipient under an incentive eamings or similar program (section 52-352b(4)) C2 Court-erdered child support payments (section 52-352b(8)) Amount claimed to be exempt (J) Alimony and support other than child support” (section 52-352(14)) if less than the entire smount: *See Note Regarding Exemption for Almany and Suppart on back/page 2. ‘Signed Bate signed ‘Telopirone number ‘Compieie maiing address of Judgment Debior Subscribed and swom Baie At (Fowny Signed (Notary Public. Commissioncr of Supcrios Court} Jo before me‘on ; ——= an Page 1 of 2 Instructions 21-11342 To Financial Institution To Clerk 4 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 returns this form claiming an exemption, title 42a pursuant to General Statutes § 52-367b and enter the appearance of the judgment debtor with address set forth on (2) mail notice to judgment dehtor as required by page 1. 31CFR212.6 and 212.7. Set matter down for hearing. If this claim of exemption is retumed completed, fill out Complete Section 7 below. Section 6 of this form and mail, within two business. Send fite-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 instructions on the financial institution execution form. After hearing, send copy of any order entered to the financial institution. 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 earnings for that week, or (2) the amount by which the individual's disposable earnings for that week exceed forty timas the higher af (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. General Statutes § 52-350a(4) defines “disposable earnings"as that part of the earnings 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, group life insurance premiums, health insurance premiums and federal tax levies. Section 5 - Proper Officer Must Complete this Section Name and tite of propar officer Date of service on financial institution Telephone number Section 6 - (To be completed by financial institution upon return of exemption claim form) Date claim received Date mailed to court Name of financial institation Telephone number Section 7 - Notice to Judgment Debtor and Judgment Creditor The money removed from your account(s) pursuant to this execution is 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 on the date set forth below, whichever occurs earlier. Baie of hearing Tino of hearing Cam. ‘Courtroom [i p.m. Signed (Assistant Clerk) Date signed Order : The CourtMagistrate, having held a hearing to determine the issues raised by this claim, hereby orders that: By the Court (Name of JudgeFunily Support Magistralemagistratey [TJ Judge ( rsu CC] Magistrate ‘Signed (ludge/Family Srippart Magistrate/Magistcate/Assistant Clerk) Date signed ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation vin accordance with the ADA. contact a courl clerk or an ADA contact person listed al wwwjud.cl.gov/ADA. oe — D-CV-24A (page 2) Rav. 10-24 Page 2 of 2