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FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT in
PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT
WHO IS A NATURAL PERSON, www.jud.ct.gov
APPLICATION AND EXECUTION (See page 2 for instructions to financial institution) Ma
JD-CV-24 Rev. 12-09 TEXISSUE*
C.GS, §§ 52-3566, 52-3675
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 Exemption Claim Form, JD-CV-24a and attach to this form. 2. Sign original execution.
4, Present original and 1 copy to clerk of court. Retain a copy. 3. Retum original to applicant, retain a copy for file.
Address of court Judicial district Geographic | Docket number
1061 MAIN STREET, BRIDGEPORT, CT 06604 [LJ Housing session _[] 27040, FBT-CV-14-6043317-S
Name and mailing address of Judgment Creditor or Attomey (To be completed by Judgment Creditor)
cr qT
CYRIL F. MULLINS FUNERAL HOMES, INC.
ABRAHAM M. HOFFMANN ESQ.
4154 MADISON AVE
TRUMBULL, CT 06611
L
Name(s) and address(es) of Judgment Creditor(s)
CYRIL F. MULLINS FUNERAL HOMES INC.
399 WHITE PLAINS ROAD, TRUMBULL, CT 06611
Foia|
5 _| Name(s) and address(es) of Judgment Debtors)
= | SONIA CHISHOLM
§ | 161 PASTOR WALK, MONROE, CT 06468
2 | Date ofjudgment T. Amount of judgment (include, where applicable, | 2. Amount of costs 3 Amount of judgment, costs and tees (Add 7 and 2)
<= | 11/14/2014 $7,089.13 Sree eres 2nd | $447.60 $7,506.73
% Total amount paid (it any) ‘ScTotal amount unpaid (Subtract 4 from 3) | 6. Application fee for financial institution execution (If not waived by the cour
$0.00 $7,506.73 $100.00
7. Other court ordered postjudgment costs and fees STotal ofitems 5, Gand? | Check applicable
$7,606.73 [1 postiudgment interest was ordered by the court
1s this judgment arising out of services rendered at a hospital?
No (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? [x] No Oo Yes
Ifa stay of a financial institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order?
[No Yes" \specity): DEFAULTED QN-PAYMENTS
Signed (Judgment Cronk Date Ne Telephone number
<6 lore [203-373-1350
[ T
Financial Institution Exe ition
‘
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 financial institution has one or more branch offices within your
county, upon an employee of such a branch office, such employee and such branch office having been designated by the financial
institution in accordance with regulations adopted by the commissioner of banking, for payment to you pursuant to section 52-367b(b) of the
general statutes of any nonexempt debt due said Judgment Debtor(s), which sum shall not exceed the total unpaid judgment, costs and
fees as stated above, plus postjudgment interest as ordered by the court, if applicable, plus the application fee and other court ordered
postjudgment costs and fees and your own fee. After having made such demand you are directed to serve a true and attested copy of this
execution, together with the attached affidavit and exemption claim form, with your doings For Court Use Only
endorsed thereon, with the financial institution officer upon whom such demand was made.
Said sum shall be received by you and applied on this execution in accordance with the provisions
of section 52-367b of the general statutes. You shall not serve more than one financial institution
execution per judgment debtor at a time, including copies thereof. After service of an execution on
one 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.
Hereof fail not, and make due return of this writ with your doings thereon, according to law.
Signed (Assistant Clerk) Date signed
Page 1 of 2 FINANCIAL INSTITUTION EXECUTION PROCEEDINGS.NOTE: The provisions of section 52-367b, as amended from time to time, take precedence over these instructions.
Instructions To Financial Institution Upon Receipt Of A Financial Institution Execution
When Judgment Debtor Is A Natural Person
1. If any funds are removed from the judgment debtor's account pursuant to subsection (©) 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 Form to the judgment debtor and to any secured party that is a party to a control agreement between you and such
secured party under article 9 of title 42a of the general statutes, postage pre-paid, at the last known address of the judgment debtor and
of any such secured party with respect to the affected accounts on the records of your institution.
Nn
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 readily 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 a court order. The judgment debtor shall
have access to such funds left in the judgment debtor's account. You may notify the judgment creditor that funds have been left in the
judgment debtor's account pursuant to this provision. Nothing herein shall alter the exempt status of funds which are exempt from
execution under subsection (a) of section 52-367b of the general statutes or under any other provision of state or federal law, or the right
of a judgment debtor to claim such exemption. Nothing herein shall be construed to affect any other rights or obligations of the financial
institution with regard to the funds in the judgment debtor's account.
3. You must hold the amount removed from the judgment debtor's account pursuant to this execution for fifteen days from the date you mail
the copies of this form and the Exemption Claim Form to the judgment debtor and any secured party. During such fifteen day period you
must not pay the officer serving this execution.
4. If the judgment debtor returns the Exemption Claim Form or other written notice that an exemption is being claimed, and if any secured
party delivers to you written notice of such secured party's claim of a prior perfected security interest in such deposit account, you must,
within two business days of receipt of such notice, send a copy of such notice to the clerk of the court which issued the execution. You
must continue to hold the amount removed from the judgment debtor's account for forty-five days or until a court order is received
regarding disposition of the funds, whichever occurs earlier. If no 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. If you do not receive a claim of exemption or secured party claim notice within fifteen days of the mailing to the judgment debtor and any
secured party of the execution and Exemption Claim Form you must, upon demand, forthwith pay the serving officer the amount
removed from the judgment debtor's account.
6. If no exemption claim or secured party claim notice is filed or if the court orders you to pay the serving officer an amount removed from
the judgment debtor's account not exceeding the amount due on the execution and you fail or refuse to do so, you shall be liable in an
action therefor to the judgement creditor(s) named in the execution for the amount of nonexempt monies which you fail or refuse to pay
over. If no exemption claim is filed or if the court orders you to pay the serving officer an amount removed from the judgment debtor's
account not exceeding the amount due on the execution and you fail or refuse to do so, you shall be liable in an action therefor to the
judgment creditor(s) name in the execution for the amount of nonexempt monies which you fail or refuse to pay over, excluding funds of
up to one thousand dollars which you in good faith allowed the judgment debtor to access pursuant to subsection (c) of section 52-367b
of the general statutes.
N
. If you pay exempt monies from the account of the judgment debtor contrary to these instructions, or the provisions of section 52-367b of
the general statutes, you shall be liable in an action therefor to the judgment debtor for any exempt monies so paid. If you pay exempt
monies from the account of the judgment debtor contrary to these instructions, or the provisions of section 52-367b of the general
statutes, you shall be liable in an action therefor to the judgment debtor for any exempt monies so paid and you shall refund or waive any
charges of fees by you, including, but not limited to, dishonored check fees, overdraft fees or minimum balance service charges and legal
process fees, which were assessed as a result of such payment of exempt monies.
JD-CV-24 (back/page 2) Rev. 12-09 Page 2 of 2EXEMPTION CLAIM FORM
FINANCIAL INSTITUTION EXECUTION STATE SUPERIOR COURT
JD-CV-24A Rev. 4-13 ee
C.G.S. 31-58()), 52-32 1a, 52-350a, 52-352b, 52-361a, SEE INSTRUCTIONS ON BACK/PAGE 2 www.jud.ct.gov
52-367b, 29 U.S.C. 206(a)(1)
Name and address of Judgment Debtor or Attorney
(To be completed by judgment creditor or attorney)
To: "SONIA CHISHOLM 7
161 PASTOR WALK
MONROE, CT 06468 cA
L J
Section 1 — (To be completed by judgment creditor)
Judicial Housing Geographical Name and address of Court (Number, Street, Town and Zip Code)
[X] District CI session Number SUPRIOER COURT 1061 MAIN ST, BRIDGEPORT, CT 06604
Name of case Name of Judgment Debtor Docket number
CYRIL F, MULLINS FUNERAL HOMES INC. SONIA CHISHOLM FBT-CV-14-6043317-S
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 retumed Date of mailing to Judgment Debtor
Last 4 Digits of the Account Number(s) Amount removed pursuant to execution Amount and type of readily identifiable exempt funds not 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 account(s) 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
|, 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" ail that apply to the funds contained in this account)
C2 Social Security benefits (section 52-352b(g)) ( Private pension, trust, retirement, or medical savings
(L] Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, 52-352b(m))
oO Worker's Compensation benefits (section 52-352b(g)) oO 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))
Public Assistance payments (section 52-352b(d)) QO Other claim of exempt funds (Explain basis for claim of exemption):
{_] Wages* (section 52-361)
O Wages earned by a public assistance recipient under an
incentive earnings or similar program (section 52-352b(d)) Amount claimed to be exempt
(J Court-ordered child support payments (section 52-352b(h)) if less than the entire amount:
OO Alimony and support other than child support* (section 52-352b(n))
*See Note Regarding Exemption for Wages and Alimony on back/page 2.
Signed Date signed Telephone number
‘Compiete 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 2Instructions
4
N
To Financial Institution
Complete section 2 of this form and send 2 copies
of this form and the financial institution execution
form to the judgment debtor and to any secured
party that is party to a control agreement between
the financial institution and such secured party
under article 9 of title 42a pursuant to section
52-367b of the General Statutes.
If this claim of exemption is returned completed, fill
out section 4 of this form and mail, within two
business days, to the issuing clerk's office at the
address of court indicated on the front side. See
additional instructions on the financial institution
execution form.
To Clerk
. Attach this form to each financial institution execution issued in a civil or
family matter against a judgment debtor that is a natural person.
2. Deliver the execution along with this form to the judgment creditor
requesting the execution.
3. If judgment debtor completes and returns this form claiming an
exemption, enter the appearance of the judgment debtor with address
set forth on page 1.
Set matter down for short calendar hearing.
Complete section 7 below.
. Send file-stamped copy of this form to judgment debtor and judgment
creditor.
7. After hearing, send copy of any order entered to the financial institution.
aoe
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 lesser of (1) twenty-
five per cent of the individual's disposable eamings for that week, or (2) the amount by which the individual's disposable eamings for that
week exceed forty times the higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair Labor Standards Act of 1938,
U.S.C. 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
eamings are payable.
Section 52-350a(4) of the Connecticut General Statutes defines “disposable eamings” as that part of the earings 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 title 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 claim received
Date mailed to court
Name of financial institution
Telephone number
Section 7 — Notice To Judgment Debtor And Judgment Creditor
The assets in dispute are being held for (1) forty-five days from the date the exemption claim form was received by the financial
institution designated on the front of this form or (2) until disposition is ordered by the court at a hearing to be held at short
calendar on the date set forth below, whichever occurs earlier.
Date of hearing Time of hearing Lam. ] courtroom
Ll e.m.
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable
accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
Signed (Assistant Clerk)
Date 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 Suppon Magistrate/Magistrale)
(F Judge (J Fsm
CO Magistrate
Signed (Judge/Family Support Magistrate/Magistrate/Assistant Clerk)
Date signed
JD-CV-240 (page 2) Rev. 4-13
Page 2 of 2
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FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT in PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT WHO IS A NATURAL PERSON, www.jud.ct.gov APPLICATION AND EXECUTION (See page 2 for instructions to financial institution) Ma JD-CV-24 Rev. 12-09 TEXISSUE* C.GS, §§ 52-3566, 52-3675 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 Exemption Claim Form, JD-CV-24a and attach to this form. 2. Sign original execution. 4, Present original and 1 copy to clerk of court. Retain a copy. 3. Retum original to applicant, retain a copy for file. Address of court Judicial district Geographic | Docket number 1061 MAIN STREET, BRIDGEPORT, CT 06604 [LJ Housing session _[] 27040, FBT-CV-14-6043317-S Name and mailing address of Judgment Creditor or Attomey (To be completed by Judgment Creditor) cr qT CYRIL F. MULLINS FUNERAL HOMES, INC. ABRAHAM M. HOFFMANN ESQ. 4154 MADISON AVE TRUMBULL, CT 06611 L Name(s) and address(es) of Judgment Creditor(s) CYRIL F. MULLINS FUNERAL HOMES INC. 399 WHITE PLAINS ROAD, TRUMBULL, CT 06611 Foia| 5 _| Name(s) and address(es) of Judgment Debtors) = | SONIA CHISHOLM § | 161 PASTOR WALK, MONROE, CT 06468 2 | Date ofjudgment T. Amount of judgment (include, where applicable, | 2. Amount of costs 3 Amount of judgment, costs and tees (Add 7 and 2) <= | 11/14/2014 $7,089.13 Sree eres 2nd | $447.60 $7,506.73 % Total amount paid (it any) ‘ScTotal amount unpaid (Subtract 4 from 3) | 6. Application fee for financial institution execution (If not waived by the cour $0.00 $7,506.73 $100.00 7. Other court ordered postjudgment costs and fees STotal ofitems 5, Gand? | Check applicable $7,606.73 [1 postiudgment interest was ordered by the court 1s this judgment arising out of services rendered at a hospital? No (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? [x] No Oo Yes Ifa stay of a financial institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? [No Yes" \specity): DEFAULTED QN-PAYMENTS Signed (Judgment Cronk Date Ne Telephone number <6 lore [203-373-1350 [ T Financial Institution Exe ition ‘ 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 financial institution has one or more branch offices within your county, upon an employee of such a branch office, such employee and such branch office having been designated by the financial institution in accordance with regulations adopted by the commissioner of banking, for payment to you pursuant to section 52-367b(b) of the general statutes of any nonexempt debt due said Judgment Debtor(s), which sum shall not exceed the total unpaid judgment, costs and fees as stated above, plus postjudgment interest as ordered by the court, if applicable, plus the application fee and other court ordered postjudgment costs and fees and your own fee. After having made such demand you are directed to serve a true and attested copy of this execution, together with the attached affidavit and exemption claim form, with your doings For Court Use Only endorsed thereon, with the financial institution officer upon whom such demand was made. Said sum shall be received by you and applied on this execution in accordance with the provisions of section 52-367b of the general statutes. You shall not serve more than one financial institution execution per judgment debtor at a time, including copies thereof. After service of an execution on one 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. Hereof fail not, and make due return of this writ with your doings thereon, according to law. Signed (Assistant Clerk) Date signed Page 1 of 2 FINANCIAL INSTITUTION EXECUTION PROCEEDINGS.NOTE: The provisions of section 52-367b, as amended from time to time, take precedence over these instructions. Instructions To Financial Institution Upon Receipt Of A Financial Institution Execution When Judgment Debtor Is A Natural Person 1. If any funds are removed from the judgment debtor's account pursuant to subsection (©) 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 Form to the judgment debtor and to any secured party that is a party to a control agreement between you and such secured party under article 9 of title 42a of the general statutes, postage pre-paid, at the last known address of the judgment debtor and of any such secured party with respect to the affected accounts on the records of your institution. Nn 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 readily 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 a court order. The judgment debtor shall have access to such funds left in the judgment debtor's account. You may notify the judgment creditor that funds have been left in the judgment debtor's account pursuant to this provision. Nothing herein shall alter the exempt status of funds which are exempt from execution under subsection (a) of section 52-367b of the general statutes or under any other provision of state or federal law, or the right of a judgment debtor to claim such exemption. Nothing herein shall be construed to affect any other rights or obligations of the financial institution with regard to the funds in the judgment debtor's account. 3. You must hold the amount removed from the judgment debtor's account pursuant to this execution for fifteen days from the date you mail the copies of this form and the Exemption Claim Form to the judgment debtor and any secured party. During such fifteen day period you must not pay the officer serving this execution. 4. If the judgment debtor returns the Exemption Claim Form or other written notice that an exemption is being claimed, and if any secured party delivers to you written notice of such secured party's claim of a prior perfected security interest in such deposit account, you must, within two business days of receipt of such notice, send a copy of such notice to the clerk of the court which issued the execution. You must continue to hold the amount removed from the judgment debtor's account for forty-five days or until a court order is received regarding disposition of the funds, whichever occurs earlier. If no 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. If you do not receive a claim of exemption or secured party claim notice within fifteen days of the mailing to the judgment debtor and any secured party of the execution and Exemption Claim Form you must, upon demand, forthwith pay the serving officer the amount removed from the judgment debtor's account. 6. If no exemption claim or secured party claim notice is filed or if the court orders you to pay the serving officer an amount removed from the judgment debtor's account not exceeding the amount due on the execution and you fail or refuse to do so, you shall be liable in an action therefor to the judgement creditor(s) named in the execution for the amount of nonexempt monies which you fail or refuse to pay over. If no exemption claim is filed or if the court orders you to pay the serving officer an amount removed from the judgment debtor's account not exceeding the amount due on the execution and you fail or refuse to do so, you shall be liable in an action therefor to the judgment creditor(s) name in the execution for the amount of nonexempt monies which you fail or refuse to pay over, excluding funds of up to one thousand dollars which you in good faith allowed the judgment debtor to access pursuant to subsection (c) of section 52-367b of the general statutes. N . If you pay exempt monies from the account of the judgment debtor contrary to these instructions, or the provisions of section 52-367b of the general statutes, you shall be liable in an action therefor to the judgment debtor for any exempt monies so paid. If you pay exempt monies from the account of the judgment debtor contrary to these instructions, or the provisions of section 52-367b of the general statutes, you shall be liable in an action therefor to the judgment debtor for any exempt monies so paid and you shall refund or waive any charges of fees by you, including, but not limited to, dishonored check fees, overdraft fees or minimum balance service charges and legal process fees, which were assessed as a result of such payment of exempt monies. JD-CV-24 (back/page 2) Rev. 12-09 Page 2 of 2EXEMPTION CLAIM FORM FINANCIAL INSTITUTION EXECUTION STATE SUPERIOR COURT JD-CV-24A Rev. 4-13 ee C.G.S. 31-58()), 52-32 1a, 52-350a, 52-352b, 52-361a, SEE INSTRUCTIONS ON BACK/PAGE 2 www.jud.ct.gov 52-367b, 29 U.S.C. 206(a)(1) Name and address of Judgment Debtor or Attorney (To be completed by judgment creditor or attorney) To: "SONIA CHISHOLM 7 161 PASTOR WALK MONROE, CT 06468 cA L J Section 1 — (To be completed by judgment creditor) Judicial Housing Geographical Name and address of Court (Number, Street, Town and Zip Code) [X] District CI session Number SUPRIOER COURT 1061 MAIN ST, BRIDGEPORT, CT 06604 Name of case Name of Judgment Debtor Docket number CYRIL F, MULLINS FUNERAL HOMES INC. SONIA CHISHOLM FBT-CV-14-6043317-S 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 retumed Date of mailing to Judgment Debtor Last 4 Digits of the Account Number(s) Amount removed pursuant to execution Amount and type of readily identifiable exempt funds not 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 account(s) 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 |, 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" ail that apply to the funds contained in this account) C2 Social Security benefits (section 52-352b(g)) ( Private pension, trust, retirement, or medical savings (L] Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, 52-352b(m)) oO Worker's Compensation benefits (section 52-352b(g)) oO 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)) Public Assistance payments (section 52-352b(d)) QO Other claim of exempt funds (Explain basis for claim of exemption): {_] Wages* (section 52-361) O Wages earned by a public assistance recipient under an incentive earnings or similar program (section 52-352b(d)) Amount claimed to be exempt (J Court-ordered child support payments (section 52-352b(h)) if less than the entire amount: OO Alimony and support other than child support* (section 52-352b(n)) *See Note Regarding Exemption for Wages and Alimony on back/page 2. Signed Date signed Telephone number ‘Compiete 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 2Instructions 4 N To Financial Institution Complete section 2 of this form and send 2 copies of this form and the financial institution execution form to the judgment debtor and to any secured party that is party to a control agreement between the financial institution and such secured party under article 9 of title 42a pursuant to section 52-367b of the General Statutes. If this claim of exemption is returned completed, fill out section 4 of this form and mail, within two business days, to the issuing clerk's office at the address of court indicated on the front side. See additional instructions on the financial institution execution form. To Clerk . Attach this form to each financial institution execution issued in a civil or family matter against a judgment debtor that is a natural person. 2. Deliver the execution along with this form to the judgment creditor requesting the execution. 3. If judgment debtor completes and returns this form claiming an exemption, enter the appearance of the judgment debtor with address set forth on page 1. Set matter down for short calendar hearing. Complete section 7 below. . Send file-stamped copy of this form to judgment debtor and judgment creditor. 7. After hearing, send copy of any order entered to the financial institution. aoe 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 lesser of (1) twenty- five per cent of the individual's disposable eamings for that week, or (2) the amount by which the individual's disposable eamings for that week exceed forty times the higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair Labor Standards Act of 1938, U.S.C. 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 eamings are payable. Section 52-350a(4) of the Connecticut General Statutes defines “disposable eamings” as that part of the earings 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 title 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 claim received Date mailed to court Name of financial institution Telephone number Section 7 — Notice To Judgment Debtor And Judgment Creditor The assets in dispute are being held for (1) forty-five days from the date the exemption claim form was received by the financial institution designated on the front of this form or (2) until disposition is ordered by the court at a hearing to be held at short calendar on the date set forth below, whichever occurs earlier. Date of hearing Time of hearing Lam. ] courtroom Ll e.m. ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Signed (Assistant Clerk) Date 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 Suppon Magistrate/Magistrale) (F Judge (J Fsm CO Magistrate Signed (Judge/Family Support Magistrate/Magistrate/Assistant Clerk) Date signed JD-CV-240 (page 2) Rev. 4-13 Page 2 of 2