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FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT
PROCEEDI NGS - JUDGMENT DEBTOR SUPERIOR COURT ii
IUlll 1111
11111111111111111
" APFEABA"
WHO IS A NATURAL PERSON, www.jud.ct.gov
APPLICATION AND EXECUTION
JD-CV-24 Rev. 2-1.5 (See page 2 for instructions to financial institution I
11111111111111111HI 1~111111
· EX I SSUE •
C.G.S.§§52-356b, 52-367b and ADA Notice)
P.A. 14-7, 14-9
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, JO-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. Return original to applicant, retain a copy for file.
Address of court
X Judicial district Geographic
area
Docket number
1 Court Street Middletown, CT 06457 Housing session D number _ _ MMX-CV-18-6021881-S
Name and mailing address of Judgment Creditor or Attorney (To be completed by Judgment Creditor)
r CAPITAL ONE BANK (USA), N.A.
C/O London & London
48 Christian Lane
Newington, CT 06111 18-61507
L _J
Name(s) and address(es) of Judgment Creditor(s)
C/O London & London
CAPITAL ONE BANK (USA), N.A. 48 Christian Lane, Newington, CT 06111
Name(s) and address(es) of Judgment Debtor(s)
49 FAIRVIEW ST
MICHAEL L FARMER
PORTLAND CT 06480-1563
Date of judgment 1. Amount of Judgment 2. Amount of costs
(Include. where applicable, 3. Amount of judgment, costs and fees (Add 1 and 2)
prejudgment interest and
08/29/2018 5324.97 attorne 's fees 447.05 5772.02
4. Total amount paid (If any) ,
5.Total amount unpaid
(Subtract 4 from 3) 6. Application fee for financial institution execution (If not waived by the court)
1221.43 4550.59 105.00
7. Application fees paid for prior executions on lhis judgment
? 8. other court ordered postjudgment costs and fees
' 9.Total of items 5, 6 , 7 and 8
105.00 0.00 4760.59
Check if applicable
?
Dx D
Is this judgment arising out of services rendered at a hospital? '
No Yes DX postjudgment interest was ordered by the court
x D
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? Yes
If a stay of a financial institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? ?
No Dx Yes (Specify): weekly payments of 35.00 beginning on 09/20/2018
Signed(Judgment Creditor or Attorney) Date signed Telephone number
400805 Russell L. London 01/20/2020 860-666-4500
Financial Institution Execution
To any proper officer,
Whereas on said Date of Judgment the above-named Judgment Creditor(s) recovered judgment against the above-named Judgment Debtor(s) before the above-
named court for the amount of judgment, costs and fees stated above, as appears of record, whereof execution remains to be done.
These are, therefore, by authority of the state of Connecticut to command you:
Within seven days from your receipt of this execution, make demand upon the main office of any financia l 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 e mployee of such a branch office, such
employee and such branch office having been designated by the financia l institution in accordance w ith 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 Oebtor(s), which sum shall not exceed the total
unpaid judgment, costs and fees as stated above, plus postjudgment interest as ordered by the court, if applicable, plus the application fee and other court ordered
postjudgment costs and fees and your own fee. After having made such demand you are directed to serve a true and attested copy of this execution, together with the
attached affidavit and exemption claim form , with your doings endorsed thereon, with the financial institution officer upon whom such demand was made. Said sum
shall be rece ived 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
For Court Use Only
financial institution execution per judgment debtor at a time, including copies the reof. 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 financia l institution that the judgment debtor had insufficient funds at the preceding financial
institution ava ilable for collection to satisfy the execution, provided any such additiona l 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 or a
copy thereof upon such financial institution if an electronic direct deposit from a readily identifiable source described in
section 52 -376b (c) of the General Statutes was made to the judgment debtor's account within the look-back period
described in section 52 -376b (c) of the General Statues (sixty days or, with regard to federal benefits, such greater period as
required by federal law). 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 otherwise become unenforceable.
Hereof fail not, and make due return of this writ with your doings thereon, according to law.
Signed ( Assistant Clerk) IDate signed
Page 1 of 2 FINANCIAL INSTITUTION EXECUTION PROCEEDINGS
Print Form I Reset Form I
18-61507
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 (c) of section 52-367b of the General Statutes,
complete section II of the accompanying Exemption Claim Form (JD-CV-24a) and (1) send, forthwith, 2 copies of both this form and the
Exemption Claim Form to the judgment debtor and to any secured party that is a party to a control agreement between you and such
secured party under article 9 of title 42a of the General Statutes, postage pre-paid, at the last known address of the judgment debtor and
of any such secured party with respect to the affected accounts on the records of your institution and (2) mail notice to the judgment
debtor as required by 31CFR212.6 and 212.7.
2. Remove from the judgment debtor's account the amount of any debts due from you to the judgment debtor not exceeding the Total
Amount Unpaid as appears on page 1 of this form plus interest and the Application Fee for Financial Institution Execution and other court
ordered postjudgment costs or fees and the serving officer's fee, before your midnight deadline, as defined in section 42a-4-104 of the
General Statutes. Ifan electronic direct deposit isreadily identifiable asexempt 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 section 52-352b of the Connecticut General Statutes, 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 look-back period of either the sixty-day period preceding
the date that the execution was served on you, or, with regard to federal benefits, such greater period as required by federal law then you
shallleave 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 inthe 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 shallbe construed to affect any other rightsor 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 untila court order isreceived
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 officerthe 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.
7. If you pay exempt monies from the account of the judgment debtor contrary to these instructions, or the provisions of section 52-367b of
the General Statutes, you shall be liable in an action therefor to the judgment debtor for any exempt monies so paid. If you pay exempt
monies from the account of the judgment debtor contrary to these instructions,or the provisions of section 52-367b of the General
Statutes, you shall be liable in an action therefor to the judgment debtor for any exempt monies so paid and you shall refund or waive
any charges of fees by you, including, but not limited to, dishonored check fees, overdraft fees or minimum balance service charges and
legal process fees, which were assessed as a result of such payment of exempt monies.
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the
ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
JD-CV-24 (back/page 2)
Rev. 2-15 Page 2 of 2
=-""" ..,""'=-
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.......,Pr i nt Fo-r-m I Reset
- FormJ
EXEMPTION CLAIM FORM STATE OF CONNECTICUT
FINANCIAL INSTITUTION EXECUTION
JD-CV-24A Rev. 1-17
SUPERIOR COURT
SEE
C.G.S. 31-SB(i), 52-321a, 52-350a, 52-352b, 52-361a, 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 attomey)
For court use only
To: r MICHAEL L FARMER 1
MXMPEX
49 FAIRVIEW ST 11111111111111111mm111111
PORTLAND CT 06480-1563
L J 18-61507
Section 1 - (To be completed by judgment creditor)
Housing Geographical Name and address of Court
(Number, Street, Town and Zip Code)
Judicial
Dx District D Session D Area
Number SUPERIOR COURT 1 Court Street Middletown, CT 06457
Name of case Name of Judgment Debtor Docket number
CAPITAL ONE BANK (USA), N.A.
MICHAEL L FARMER
MMX-CV-18-6021881-S
v. MICHAEL L FARMER
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 I Date of mailing to Ju dgment Debtor
Last 4 Digits of the Account Number(s) Amount removed pursuant to execution Amount and type of readily identifiable exempt funds not removed
D Additional sheet(s) attached hereto and made a part hereof (if necessary).
Section 3 - Notice To Judgment Debtor
As a result of a judgment entered against you, the attached execution has been issued against funds deposited by you in the
financial institution named above. To comply with this execution, the financial institution has removed the amount of money indicated
above from the account(s) listed above.
THE MONEY IN YOUR ACCOUNT($) MAY BE EXEMPT FROM EXECUTION - The money in your account(s) may be protected from
execution by state statutes or by other laws or regulations of Connecticut or of the United States. A checklist and a description of the most
common exemptions established by law are set forth below.
HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW. If you wish to claim that the money in your account(s) is exempt by law
from execution, you must fill out and sign before a proper official the Affidavit of Claim of Exemption below and mail or deliver this
exemption claim form to the financial institution at the above address. This form must be received by the financial institution no later than
15 days from the DATE OF MAILING TO THE JUDGMENT DEBTOR indicated above.
Upon receipt of this form the financial institution will send it to the Superior Court and the court clerk will notify you and the judgment
creditor of the date on which a hearing will be held by the court to determine the issues raised by your claim.
SECTION 4 - AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW
I, the judgment debtor named above, claim and certify under the penalty of false statement that the money in the above account
is exempt by law from execution as follows: ("X" all that apply to the funds contained in this account)
D Social Security benefits (section 52-352b(g)) D Private pension, trust, retirement, or medical savings
D Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, 52-352b(m))
D Worker's Compensation benefits (section 52-352b(g)) D Health or disability insurance payments (section 52-352b(e))
D Veteran's benefits (section 52-352b(g)) D An amount in the bank not to exceed $1000 (section 52-352b(r))
D Public Assistance payments (section 52-352b(d)) D Other claim of exempt funds (Explain basis for claim of exemption):
D Wages earned by a public assistance recipient under an
incentive earnings or similar program (section 52-352b(d))
D Court-ordered child support payments (section 52-352b(h)) Amount claimed to be exempt
D 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 I Date signed I 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 of2
Print Form Reset Form
18-61507
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 instit ution execution issued in a civil or
of this form and the financial institution execution form family matter against a judgment debtor t hat 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 fi nancial requesting the execution.
institution and such secured party under article 9 of 3. If judgment debtor completes and returns this form claiming an
title 42a pursuant to section 52-367b of the Genera I exemption, enter the appearance of t he j udgment debtor w ith address
Statutes and (2) mail notice to judgment debtor as set forth on page 1.
required by 31CFR212.6 and 212.7.
4. Set matter down for short calendar hearing.
2. If this claim of exemption is returned completed, f ill out 5. Complete section 7 below.
section 6 of this form and mail, within two business 6. Send file-sta mped copy of t his form to judgment debtor and judgment
days, to the issuing clerk's office at t he address of creditor.
court indicated on the front side. See additional 7. After hearing, send copy of any order entered to the financial institution.
instructions on t he financial institution execution fo rm.
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 supporl, 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 (8), the state minimum hourly wage under subsection(!) 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 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 Telephon e number
Section 6 - (To be completed by financial institution upon return of exemption claim form)
Date cl aim received Date m ailed to court Name of fi nan cial institution Telephon e number
Section 7 - Notice To Judg ment Debtor And Judgment Creditor
The assets in dispute are being held for (1 ) forty-fi ve days from the date the exemption claim form was recei ved by the fin ancial
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 a. m. Courtroom
p.m.
Signed(Assistant Clerk) I Date signed
Order
T he Court/Magistrate, having held a hearing to determ ine the issues raised by this c laim, hereby orders t hat:
By the Court
(Name of Judge/Family Support Magistrate/Magistrate)
D Judge D FSM D Magistrate
Signed(Judge/Family Support Magistrate/Magistrate/Assistant Clerk) Date signed
ADA NOTICE
The Judicial Branch of t he State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable
accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
JD-CV-24A (page 2)
Rev. 1-17 Page2 of2
Print Form Reset Form
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FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT PROCEEDI NGS - JUDGMENT DEBTOR SUPERIOR COURT ii IUlll 1111 11111111111111111 " APFEABA" WHO IS A NATURAL PERSON, www.jud.ct.gov APPLICATION AND EXECUTION JD-CV-24 Rev. 2-1.5 (See page 2 for instructions to financial institution I 11111111111111111HI 1~111111 · EX I SSUE • C.G.S.§§52-356b, 52-367b and ADA Notice) P.A. 14-7, 14-9 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, JO-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. Return original to applicant, retain a copy for file. Address of court X Judicial district Geographic area Docket number 1 Court Street Middletown, CT 06457 Housing session D number _ _ MMX-CV-18-6021881-S Name and mailing address of Judgment Creditor or Attorney (To be completed by Judgment Creditor) r CAPITAL ONE BANK (USA), N.A. C/O London & London 48 Christian Lane Newington, CT 06111 18-61507 L _J Name(s) and address(es) of Judgment Creditor(s) C/O London & London CAPITAL ONE BANK (USA), N.A. 48 Christian Lane, Newington, CT 06111 Name(s) and address(es) of Judgment Debtor(s) 49 FAIRVIEW ST MICHAEL L FARMER PORTLAND CT 06480-1563 Date of judgment 1. Amount of Judgment 2. Amount of costs (Include. where applicable, 3. Amount of judgment, costs and fees (Add 1 and 2) prejudgment interest and 08/29/2018 5324.97 attorne 's fees 447.05 5772.02 4. Total amount paid (If any) , 5.Total amount unpaid (Subtract 4 from 3) 6. Application fee for financial institution execution (If not waived by the court) 1221.43 4550.59 105.00 7. Application fees paid for prior executions on lhis judgment ? 8. other court ordered postjudgment costs and fees ' 9.Total of items 5, 6 , 7 and 8 105.00 0.00 4760.59 Check if applicable ? Dx D Is this judgment arising out of services rendered at a hospital? ' No Yes DX postjudgment interest was ordered by the court x D 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? Yes If a stay of a financial institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? ? No Dx Yes (Specify): weekly payments of 35.00 beginning on 09/20/2018 Signed(Judgment Creditor or Attorney) Date signed Telephone number 400805 Russell L. London 01/20/2020 860-666-4500 Financial Institution Execution To any proper officer, Whereas on said Date of Judgment the above-named Judgment Creditor(s) recovered judgment against the above-named Judgment Debtor(s) before the above- named court for the amount of judgment, costs and fees stated above, as appears of record, whereof execution remains to be done. These are, therefore, by authority of the state of Connecticut to command you: Within seven days from your receipt of this execution, make demand upon the main office of any financia l 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 e mployee of such a branch office, such employee and such branch office having been designated by the financia l institution in accordance w ith 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 Oebtor(s), which sum shall not exceed the total unpaid judgment, costs and fees as stated above, plus postjudgment interest as ordered by the court, if applicable, plus the application fee and other court ordered postjudgment costs and fees and your own fee. After having made such demand you are directed to serve a true and attested copy of this execution, together with the attached affidavit and exemption claim form , with your doings endorsed thereon, with the financial institution officer upon whom such demand was made. Said sum shall be rece ived 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 For Court Use Only financial institution execution per judgment debtor at a time, including copies the reof. 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 financia l institution that the judgment debtor had insufficient funds at the preceding financial institution ava ilable for collection to satisfy the execution, provided any such additiona l 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 or a copy thereof upon such financial institution if an electronic direct deposit from a readily identifiable source described in section 52 -376b (c) of the General Statutes was made to the judgment debtor's account within the look-back period described in section 52 -376b (c) of the General Statues (sixty days or, with regard to federal benefits, such greater period as required by federal law). 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 otherwise become unenforceable. Hereof fail not, and make due return of this writ with your doings thereon, according to law. Signed ( Assistant Clerk) IDate signed Page 1 of 2 FINANCIAL INSTITUTION EXECUTION PROCEEDINGS Print Form I Reset Form I 18-61507 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 (c) of section 52-367b of the General Statutes, complete section II of the accompanying Exemption Claim Form (JD-CV-24a) and (1) send, forthwith, 2 copies of both this form and the Exemption Claim Form to the judgment debtor and to any secured party that is a party to a control agreement between you and such secured party under article 9 of title 42a of the General Statutes, postage pre-paid, at the last known address of the judgment debtor and of any such secured party with respect to the affected accounts on the records of your institution and (2) mail notice to the judgment debtor as required by 31CFR212.6 and 212.7. 2. Remove from the judgment debtor's account the amount of any debts due from you to the judgment debtor not exceeding the Total Amount Unpaid as appears on page 1 of this form plus interest and the Application Fee for Financial Institution Execution and other court ordered postjudgment costs or fees and the serving officer's fee, before your midnight deadline, as defined in section 42a-4-104 of the General Statutes. Ifan electronic direct deposit isreadily identifiable asexempt 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 section 52-352b of the Connecticut General Statutes, 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 look-back period of either the sixty-day period preceding the date that the execution was served on you, or, with regard to federal benefits, such greater period as required by federal law then you shallleave 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 inthe 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 shallbe construed to affect any other rightsor 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 untila court order isreceived 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 officerthe 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. 7. If you pay exempt monies from the account of the judgment debtor contrary to these instructions, or the provisions of section 52-367b of the General Statutes, you shall be liable in an action therefor to the judgment debtor for any exempt monies so paid. If you pay exempt monies from the account of the judgment debtor contrary to these instructions,or the provisions of section 52-367b of the General Statutes, you shall be liable in an action therefor to the judgment debtor for any exempt monies so paid and you shall refund or waive any charges of fees by you, including, but not limited to, dishonored check fees, overdraft fees or minimum balance service charges and legal process fees, which were assessed as a result of such payment of exempt monies. ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. JD-CV-24 (back/page 2) Rev. 2-15 Page 2 of 2 =-""" ..,""'=- ---. .......,Pr i nt Fo-r-m I Reset - FormJ EXEMPTION CLAIM FORM STATE OF CONNECTICUT FINANCIAL INSTITUTION EXECUTION JD-CV-24A Rev. 1-17 SUPERIOR COURT SEE C.G.S. 31-SB(i), 52-321a, 52-350a, 52-352b, 52-361a, 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 attomey) For court use only To: r MICHAEL L FARMER 1 MXMPEX 49 FAIRVIEW ST 11111111111111111mm111111 PORTLAND CT 06480-1563 L J 18-61507 Section 1 - (To be completed by judgment creditor) Housing Geographical Name and address of Court (Number, Street, Town and Zip Code) Judicial Dx District D Session D Area Number SUPERIOR COURT 1 Court Street Middletown, CT 06457 Name of case Name of Judgment Debtor Docket number CAPITAL ONE BANK (USA), N.A. MICHAEL L FARMER MMX-CV-18-6021881-S v. MICHAEL L FARMER 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 I Date of mailing to Ju dgment Debtor Last 4 Digits of the Account Number(s) Amount removed pursuant to execution Amount and type of readily identifiable exempt funds not removed D Additional sheet(s) attached hereto and made a part hereof (if necessary). Section 3 - Notice To Judgment Debtor As a result of a judgment entered against you, the attached execution has been issued against funds deposited by you in the financial institution named above. To comply with this execution, the financial institution has removed the amount of money indicated above from the account(s) listed above. THE MONEY IN YOUR ACCOUNT($) MAY BE EXEMPT FROM EXECUTION - The money in your account(s) may be protected from execution by state statutes or by other laws or regulations of Connecticut or of the United States. A checklist and a description of the most common exemptions established by law are set forth below. HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW. If you wish to claim that the money in your account(s) is exempt by law from execution, you must fill out and sign before a proper official the Affidavit of Claim of Exemption below and mail or deliver this exemption claim form to the financial institution at the above address. This form must be received by the financial institution no later than 15 days from the DATE OF MAILING TO THE JUDGMENT DEBTOR indicated above. Upon receipt of this form the financial institution will send it to the Superior Court and the court clerk will notify you and the judgment creditor of the date on which a hearing will be held by the court to determine the issues raised by your claim. SECTION 4 - AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW I, the judgment debtor named above, claim and certify under the penalty of false statement that the money in the above account is exempt by law from execution as follows: ("X" all that apply to the funds contained in this account) D Social Security benefits (section 52-352b(g)) D Private pension, trust, retirement, or medical savings D Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, 52-352b(m)) D Worker's Compensation benefits (section 52-352b(g)) D Health or disability insurance payments (section 52-352b(e)) D Veteran's benefits (section 52-352b(g)) D An amount in the bank not to exceed $1000 (section 52-352b(r)) D Public Assistance payments (section 52-352b(d)) D Other claim of exempt funds (Explain basis for claim of exemption): D Wages earned by a public assistance recipient under an incentive earnings or similar program (section 52-352b(d)) D Court-ordered child support payments (section 52-352b(h)) Amount claimed to be exempt D 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 I Date signed I 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 of2 Print Form Reset Form 18-61507 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 instit ution execution issued in a civil or of this form and the financial institution execution form family matter against a judgment debtor t hat 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 fi nancial requesting the execution. institution and such secured party under article 9 of 3. If judgment debtor completes and returns this form claiming an title 42a pursuant to section 52-367b of the Genera I exemption, enter the appearance of t he j udgment debtor w ith address Statutes and (2) mail notice to judgment debtor as set forth on page 1. required by 31CFR212.6 and 212.7. 4. Set matter down for short calendar hearing. 2. If this claim of exemption is returned completed, f ill out 5. Complete section 7 below. section 6 of this form and mail, within two business 6. Send file-sta mped copy of t his form to judgment debtor and judgment days, to the issuing clerk's office at t he address of creditor. court indicated on the front side. See additional 7. After hearing, send copy of any order entered to the financial institution. instructions on t he financial institution execution fo rm. 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 supporl, 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 (8), the state minimum hourly wage under subsection(!) 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 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 Telephon e number Section 6 - (To be completed by financial institution upon return of exemption claim form) Date cl aim received Date m ailed to court Name of fi nan cial institution Telephon e number Section 7 - Notice To Judg ment Debtor And Judgment Creditor The assets in dispute are being held for (1 ) forty-fi ve days from the date the exemption claim form was recei ved by the fin ancial 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 a. m. Courtroom p.m. Signed(Assistant Clerk) I Date signed Order T he Court/Magistrate, having held a hearing to determ ine the issues raised by this c laim, hereby orders t hat: By the Court (Name of Judge/Family Support Magistrate/Magistrate) D Judge D FSM D Magistrate Signed(Judge/Family Support Magistrate/Magistrate/Assistant Clerk) Date signed ADA NOTICE The Judicial Branch of t he State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. JD-CV-24A (page 2) Rev. 1-17 Page2 of2 Print Form Reset Form