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FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT
PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT (A
*APFEABA*
WHO IS A NATURAL PERSON, www.jud.ct.gov
APPLICATION AND EXECUTION
JD-CV-24 Rev. 2-15
C.G.S. §§ 52-356b, 52-367b
(See page 2 for instructions to financial institution INCU
“EXISSUE*
and ADA Notice)
PA. 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 and2 copies. on the application is correct.
3. Complete section 1 of the Exemption Claim Form, JD-CV-24a and attach to tise 2. Sign original execution. Y11741
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 [A suciciat district Geographic Docket number
PO BOX 247 LITCHFIELD CT 06759 [_] Housing session D1 humoer
Name and mailing address of Judgment Creditor or Attorney (To be completed by Judgment Creditor) ICV146011199S
Law Offices 7d
Howard Lee Schiff,P.C,.
P.O.Box 280245
E Hartford, CT 06128 0245
L
Name(s) and address(es) of Judgment Creditor(s)
CAPITAL ONE BANK USA, N.A,
RICHMOND, VA
Name(s) and address(es) of Judgment Debtor(s)
GREGORY B ESKER, SR
214 SMITH HILL RD WINSTED, CT 06098
Date of judgment T. Amount of judgment (Include, where applicable, | 2. Amountof costs 3. Amount of judgment, costs and fees (Add 1 and 2)
7/23/15 $8,111.67 prejudgment interest and $390.16 $8,501.83
attomey's fees)
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)
$.00 $8,501.83 $100.00
T. Application fees paid for prior executions on this judgment 8. Other court ordered postjudgment costs and fees, 9-Total of items 6, 6, 7 and &
$0.00 $0.00 $8,601.83
‘Check f applicable
No [[] Yes [[] postiudgment interest was ordered by the court
If this is a judgment arising out of services rendered at a hospital, has a stay of a financial institution execution been
entered pursuant to an installment payment order? [No (1 Yes
fa stay of a financial institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order?
[] No LJ Yes (Specify):
Date sig
PC thtopher Moyian, ESQ if (4 ha
Telephone number
(860) 5286-9991
Financial Ingfitution Execution T
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,
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 for 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.
sum Said
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 For Court Use Only
confirmation from the preceding financial institution that the judgment debtor had insufficient funds at the preceding financial
institution available for collection to satisfy the execution, provided any such additional service is made not later than forty-five
days from the receipt by you of such execution. After service of an execution, you shall not serve the same execution 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) Date signed
XB
Page 1 of2 FINANCIAL INSTITUTION EXECUTION PROCEEDINGS.
11/11/15
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instructions.
NOTE: The provisions of section 52-367b, as amended from time to time, take precedence over these
Instructions To Financial Institution Upon Receipt Of A Financial Institution Execution
When Judgment Debtor Is A Natural Person
4 If any funds are remover d from the judgment debtor's account pursuant to subsection (c) of section 52-367b of the General Statutes,
rthwith, 2 copies of both this form and the
complete section Il of the accompanying Exemption Claim Form (JD-CV-24a) and (1) send, fo
Exemption Claim Form to the judgment debtor and to any secured party that is a party to a contro! agreement between you and such
secured party ul nder article 9 of title 42a of the General Statutes, postage pre-paid, at the last known address of the judgment debtor and
secured party. with respect to the affected accounts on the records of your institution and (2) mail notice to the judgment
of any such
debtor as required by 31CFR212.6 and 212.7.
exceeding the Total
Remove from the judgment debtor's account the amount of any debts due from you to the judgment debtor not
Amount Unpat id as appears on page 1 of this form plus interest and the Application Fee for Financial Institution Execution and other court
or fees and the serving officer's fee, before yor ur midnight deadline, as defined in section 42a-4-104 of the
ordered postjudgment costs
veterans’ benefits, Social Security benefits,
General Statutes. If an electronic direct deposit is readily identifiable as exempt federal
benefits, exempt benefits paid by
including, but not limited to, retirement, survivors’ and disability benefits, supplemental security income
Board or the federal Office of Personnel Management, unemployment compensation benefits exempt
the federal Railroad Retirement
to Title !V-D of
under section 52-352b of the Connecticut General Statutes, or child support payments processed and received pursuant
during the look-back period of either the sixty-day period preceding
the Social Security Act were made to the judgment debtor's account
on you, or, with regard to federal benefits, such greater period as required by federal law then you
the date that the execution was served
nothing in this
shall leave the lesser of the account balance or one thousand dollars in the judgment debtor's account, provided
if required by any
subsection shall be construed to limit your right or obligation to remove such funds from the judgment debtor's account
The judgment debtor shall have full and customary access to such funds left in the judgment
other provision of law or by a court order.
account. You may notify the judgment creditor that funds have been left in the judgment debtor's account pursuant to this
debtor's
are exempt from execution under subsection (a) of section 52-367b
provision. Nothing herein shall alter the exempt status of funds which
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.
in the
Nothing herein shall be construed to affect any other rights or obligations of the financial institution with regard to the funds
judgment debtor's account.
from the date you mail
You must hold the amount removed from the judgment debtor's account pursuant to this execution for fifteen days
you
the copies of this form and the Exemption Claim Form to the judgment debtor and any secured party. During such fifteen day period
must not pay the officer serving this execution.
secured
If the judgment debtor retums the Exemption Claim Form or other written notice that an exemption is being claimed, and if any
to you written notice of such secured party's claim of a prior perfected security interest in such deposit account, you must,
party delivers
the execution. You
within two business days of receipt of such notice, send a copy of such notice to the clerk of the court which issued
received
must continue to hold the amount removed from the judgment debtor's account for forty-five days or until a court order is
of the funds, whichever occurs earlier. If no order is received within forty-five days of the date you send a copy of
regarding disposition
return the funds to
the Exemption Claim Form or notice of exemption or a secured party claim notice to the clerk of the court, you mnast
the judgment debtor's account. i
debtor and any
If you do not receive a claim of exemption or secured party claim notice within fifteen days of the mailing to the judgment
Claim Form you must, upon demand, forthwith pay the serving officer the amount
secured party of the execution and Exemption
removed from the judgment debtor's account.
officer an amount removed from
If no exemption claim or secured party claim notice is filed or if the court orders you to pay the serving
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
to pay over, excluding funds of
judgment creditor(s) name in the execution for the amount of nonexempt monies which you fail or refuse
(c) of section §2-367b
up to one thousand dollars which you in good faith allowed the judgment debtor to access pursuant fo subsection
of the General Statutes.
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 ac tion therefor to the judgment debtor for any exempt monies so paid and you shall refund or waive
minimum balance service charges and
any charges of fees by you, including, but not limited to, dishonored check fees, overdraft fees or
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). {f you need a reasonable accommodation in accordance with the
ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gav/ADA,
JD-CV-24 (back/page
2) Rev. 2-15 Page 2 of 2
as a
EXEMPTION CLAIM FORM
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FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT
JD-CV-24A Rev. 2-15 SUPERIOR COURT
C.G.S. 31-58(i), 52-321, 52-350a, 52-352b, 52-361a, SEE INSTRUCTIONS ON BACKIPAGE 2
52-367b, 29 U.S.C. 206(a)(1) www jud.ct.gov ae
Name and address of Judgment Debtor or Attormey
(To be completed by judgment creditor or attorney)
To:
La
YE
MTT 1 +
ER y SF
A. RD
CN YLi7ii l
OS
THIS OMPILIN I ay CON te
L WINSTED, CT 06! O98 FROM A DEBT COLL STOR
Section 1— (To be completed by judgment creditor)
Judicial Housing Geographical Name and address of Court (Number, Street, Town and Zip Code)
Ci bistrict Ll Session
Area
Number PO BOX B47 LITOHE » CT 067359
Name of case Name of Judgment Debior Docket number
tS AL. ONE BAN! USA, NuAw GREGORY B ESI nFy SR
1 CV146011199S
GR GORY Et E Ra SR
Section 2 — (To be completed by financial institution - see instructions on back/pa
ge 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
{J 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 executi: ion 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 AGCOUNT(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 de: scription 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 th 1e Affidavit of
Claim of Exemption below and mail or deliver this
exemption claim form to the financial institution at the above add ress. This form must
be received by the financial institution no later than
15 days from the DATE OF MAILING TO THE JUDGMENT DEBT! ‘OR indicated above.
Upon receipt of this form the financial institution will forward it to the Su perior
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 determi
ine the issues raised by your claim.
SECTION 4 — AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW
|, the judgment debtor named above, claim and certi ify under the penalty of false
statement that the money in the above account
is exempt by law from execution as follows: ("x" all that apply to the funds contained in this account)
(J Social Security benefits (section 52-352b(g)) {_] Private pension, trust, retirement, or medical savings
[_] Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, 52-352b(m))
[_] Worker's Compensation benefits (section 62-352b(g)) [_] Health or disability insurance payments (section 52-352b(e))
LL Veteran's benefits (section 52-352b(g)) {_] An amount in the bank not to exceed $1000 (section 52-352b(r))
[_] Public Assistance payments (section §2-352b(d)) [J Other claim of exempt funds (Explain basis for claim of exemption)
(_] Wages* (section 52-361a)
[_] 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:
LJ Alimony and support other than child support* (section §2-352b(n))
*See Note Regarding Exemption for Wages and Alimony on back/page 2.
Signed Date signed ] Telephone number
Complete mailing address of Judgment Debtor
Subscribed and sworn Date Al (Town) Signed (Notary Public, Commissioner of Superior Court)
to before me on :
Page 1 of2
te. .4
® e
Instructions
To Clerk
To Financial Institution
or
4. Complete section 2 of this farm and (1) send 2 copies Attach this form to each financial institution execution issued in a civil
family matter against a judgment debtor that is a natural person.
of this form and the financial institution execution form
to the judgment debtor and to any secured party that Deliver the execution along with this form to the judgment creditor
is party to a control agreement between the financial requesting the execution.
institution and such secured party under article 9 of If judgment debtor completes and returns this form claiming an
title 42a pursuant to section 52-367 of the General exemption, enter the appearance of the judgment debtor with address
Statutes and (2) mail notice to judgment debtor as set forth on page 1.
required by 31CFR212.6 and 212.7 Set matter down for short calendar hearing.
Complete section 7 below.
2. If this claim of exemption is returned completed, fill out
Send file-stamped copy of this form to judgment debtor and judgment
section 4 of this form and mail, within two business
days, to the issuing clerk's office at the address of creditor.
court indicated on the front side. See additional After hearing, send copy of any order entered to the financial institution.
instructions on the financial institution execution form.
Note Regarding Exemption For Wages And Alimony
withholding for payment of a judgment is the lesser of (1) twenty-
The amount of wages and alimony that may be subject to levy or other
(2) the amount by which the individual's disposable earnings for that
five per cent of the individual's disposable earnings for that weei k, or Standards Act of 1938,
un der Section 6(a)(1) of the Fair Labor
week exceed forty times the higher of (A) the federal minimum hourly wage 8, in effect at the time the
minimum hourly wage under subsection (i) of Section 31-5:
U.S.C. tit, 29, Section 206(a)(1), or (B), the state
earnings are payable.
e earnings" as that part of the eamings of an individual
Section 52-350a(4) of the Connecticut General Statutes defines "disposabl income and employment
be withheld for payment of federal
remaining after the deduction from those earnings of amounts require .d to
ons, union dues and initiation fees, group life insurance premiums, health insurance premiums and
taxes, normal retirement contributi
federal tax levies.
Section 5 — Proper Officer Must Complete This Section Telephone number
Name and title of proper officer Dale of service an financial institution
se
claim form)
Section 6 — (To be completed by financial institution upon return of exemption
Date mailed to court Name of financial institution ‘Telephone number
Date claim received
a
“Section 7 — Notice To Judgment Debtor And Judgment Creditor
date the exemption claim form was received by the financial
The assets in dispute are being held for (1) forty-five day: 5 from the
institution designated on the front of this form or (2) untit | dispositio n is ordered by the court at a hearing to be held at short
calendar on the date set forth below, whichever occurs earlier.
Date ofhearing Time of hearing Liam. Courtroom
Lhem
ADA NOTICE
Act (ADA). If you need a reasonable
The Judicial Bran: ch of the State of Connecticut complies with the Americans with Disabilities
contact person listed at www jud.ct.gov/ADA
accommodation in accordance with the ADA, contact a court clerk ar an ADA
= Date signed
“Bigned (Assistan
. a scsi
Order
this claim, hereby orders that
The Court/Magistrate, having held a hearing to determine the issues raised by
“Bythe Coun (Name of Judge/Family Support ‘Magistrate/Magistrate)
o Judge [_] FSM [77 Magistrate
Date signed
Signed (ludge/Family Support Tagistrate/Magistrate/Assistant Clerk)
ee
s = si
JD-CV-24A (page 2) Rev. 2-15 Page 2 of 2
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5 ip @ . FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT (A *APFEABA* WHO IS A NATURAL PERSON, www.jud.ct.gov APPLICATION AND EXECUTION JD-CV-24 Rev. 2-15 C.G.S. §§ 52-356b, 52-367b (See page 2 for instructions to financial institution INCU “EXISSUE* and ADA Notice) PA. 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 and2 copies. on the application is correct. 3. Complete section 1 of the Exemption Claim Form, JD-CV-24a and attach to tise 2. Sign original execution. Y11741 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 [A suciciat district Geographic Docket number PO BOX 247 LITCHFIELD CT 06759 [_] Housing session D1 humoer Name and mailing address of Judgment Creditor or Attorney (To be completed by Judgment Creditor) ICV146011199S Law Offices 7d Howard Lee Schiff,P.C,. P.O.Box 280245 E Hartford, CT 06128 0245 L Name(s) and address(es) of Judgment Creditor(s) CAPITAL ONE BANK USA, N.A, RICHMOND, VA Name(s) and address(es) of Judgment Debtor(s) GREGORY B ESKER, SR 214 SMITH HILL RD WINSTED, CT 06098 Date of judgment T. Amount of judgment (Include, where applicable, | 2. Amountof costs 3. Amount of judgment, costs and fees (Add 1 and 2) 7/23/15 $8,111.67 prejudgment interest and $390.16 $8,501.83 attomey's fees) 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) $.00 $8,501.83 $100.00 T. Application fees paid for prior executions on this judgment 8. Other court ordered postjudgment costs and fees, 9-Total of items 6, 6, 7 and & $0.00 $0.00 $8,601.83 ‘Check f applicable No [[] Yes [[] postiudgment interest was ordered by the court If this is a judgment arising out of services rendered at a hospital, has a stay of a financial institution execution been entered pursuant to an installment payment order? [No (1 Yes fa stay of a financial institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? [] No LJ Yes (Specify): Date sig PC thtopher Moyian, ESQ if (4 ha Telephone number (860) 5286-9991 Financial Ingfitution Execution T 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, 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 for 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. sum Said 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 For Court Use Only confirmation from the preceding financial institution that the judgment debtor had insufficient funds at the preceding financial institution available for collection to satisfy the execution, provided any such additional service is made not later than forty-five days from the receipt by you of such execution. After service of an execution, you shall not serve the same execution 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) Date signed XB Page 1 of2 FINANCIAL INSTITUTION EXECUTION PROCEEDINGS. 11/11/15 -# @ @ instructions. NOTE: The provisions of section 52-367b, as amended from time to time, take precedence over these Instructions To Financial Institution Upon Receipt Of A Financial Institution Execution When Judgment Debtor Is A Natural Person 4 If any funds are remover d from the judgment debtor's account pursuant to subsection (c) of section 52-367b of the General Statutes, rthwith, 2 copies of both this form and the complete section Il of the accompanying Exemption Claim Form (JD-CV-24a) and (1) send, fo Exemption Claim Form to the judgment debtor and to any secured party that is a party to a contro! agreement between you and such secured party ul nder article 9 of title 42a of the General Statutes, postage pre-paid, at the last known address of the judgment debtor and secured party. with respect to the affected accounts on the records of your institution and (2) mail notice to the judgment of any such debtor as required by 31CFR212.6 and 212.7. exceeding the Total Remove from the judgment debtor's account the amount of any debts due from you to the judgment debtor not Amount Unpat id as appears on page 1 of this form plus interest and the Application Fee for Financial Institution Execution and other court or fees and the serving officer's fee, before yor ur midnight deadline, as defined in section 42a-4-104 of the ordered postjudgment costs veterans’ benefits, Social Security benefits, General Statutes. If an electronic direct deposit is readily identifiable as exempt federal benefits, exempt benefits paid by including, but not limited to, retirement, survivors’ and disability benefits, supplemental security income Board or the federal Office of Personnel Management, unemployment compensation benefits exempt the federal Railroad Retirement to Title !V-D of under section 52-352b of the Connecticut General Statutes, or child support payments processed and received pursuant during the look-back period of either the sixty-day period preceding the Social Security Act were made to the judgment debtor's account on you, or, with regard to federal benefits, such greater period as required by federal law then you the date that the execution was served nothing in this shall leave the lesser of the account balance or one thousand dollars in the judgment debtor's account, provided if required by any subsection shall be construed to limit your right or obligation to remove such funds from the judgment debtor's account The judgment debtor shall have full and customary access to such funds left in the judgment other provision of law or by a court order. account. You may notify the judgment creditor that funds have been left in the judgment debtor's account pursuant to this debtor's are exempt from execution under subsection (a) of section 52-367b provision. Nothing herein shall alter the exempt status of funds which 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. in the Nothing herein shall be construed to affect any other rights or obligations of the financial institution with regard to the funds judgment debtor's account. from the date you mail You must hold the amount removed from the judgment debtor's account pursuant to this execution for fifteen days you the copies of this form and the Exemption Claim Form to the judgment debtor and any secured party. During such fifteen day period must not pay the officer serving this execution. secured If the judgment debtor retums the Exemption Claim Form or other written notice that an exemption is being claimed, and if any to you written notice of such secured party's claim of a prior perfected security interest in such deposit account, you must, party delivers the execution. You within two business days of receipt of such notice, send a copy of such notice to the clerk of the court which issued received must continue to hold the amount removed from the judgment debtor's account for forty-five days or until a court order is of the funds, whichever occurs earlier. If no order is received within forty-five days of the date you send a copy of regarding disposition return the funds to the Exemption Claim Form or notice of exemption or a secured party claim notice to the clerk of the court, you mnast the judgment debtor's account. i debtor and any If you do not receive a claim of exemption or secured party claim notice within fifteen days of the mailing to the judgment Claim Form you must, upon demand, forthwith pay the serving officer the amount secured party of the execution and Exemption removed from the judgment debtor's account. officer an amount removed from If no exemption claim or secured party claim notice is filed or if the court orders you to pay the serving 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 to pay over, excluding funds of judgment creditor(s) name in the execution for the amount of nonexempt monies which you fail or refuse (c) of section §2-367b up to one thousand dollars which you in good faith allowed the judgment debtor to access pursuant fo subsection of the General Statutes. 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 ac tion therefor to the judgment debtor for any exempt monies so paid and you shall refund or waive minimum balance service charges and any charges of fees by you, including, but not limited to, dishonored check fees, overdraft fees or 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). {f you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gav/ADA, JD-CV-24 (back/page 2) Rev. 2-15 Page 2 of 2 as a EXEMPTION CLAIM FORM ® @ FINANCIAL INSTITUTION EXECUTION STATE OF CONNECTICUT JD-CV-24A Rev. 2-15 SUPERIOR COURT C.G.S. 31-58(i), 52-321, 52-350a, 52-352b, 52-361a, SEE INSTRUCTIONS ON BACKIPAGE 2 52-367b, 29 U.S.C. 206(a)(1) www jud.ct.gov ae Name and address of Judgment Debtor or Attormey (To be completed by judgment creditor or attorney) To: La YE MTT 1 + ER y SF A. RD CN YLi7ii l OS THIS OMPILIN I ay CON te L WINSTED, CT 06! O98 FROM A DEBT COLL STOR Section 1— (To be completed by judgment creditor) Judicial Housing Geographical Name and address of Court (Number, Street, Town and Zip Code) Ci bistrict Ll Session Area Number PO BOX B47 LITOHE » CT 067359 Name of case Name of Judgment Debior Docket number tS AL. ONE BAN! USA, NuAw GREGORY B ESI nFy SR 1 CV146011199S GR GORY Et E Ra SR Section 2 — (To be completed by financial institution - see instructions on back/pa ge 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 {J 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 executi: ion 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 AGCOUNT(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 de: scription 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 th 1e Affidavit of Claim of Exemption below and mail or deliver this exemption claim form to the financial institution at the above add ress. This form must be received by the financial institution no later than 15 days from the DATE OF MAILING TO THE JUDGMENT DEBT! ‘OR indicated above. Upon receipt of this form the financial institution will forward it to the Su perior 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 determi ine the issues raised by your claim. SECTION 4 — AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW |, the judgment debtor named above, claim and certi ify under the penalty of false statement that the money in the above account is exempt by law from execution as follows: ("x" all that apply to the funds contained in this account) (J Social Security benefits (section 52-352b(g)) {_] Private pension, trust, retirement, or medical savings [_] Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, 52-352b(m)) [_] Worker's Compensation benefits (section 62-352b(g)) [_] Health or disability insurance payments (section 52-352b(e)) LL Veteran's benefits (section 52-352b(g)) {_] An amount in the bank not to exceed $1000 (section 52-352b(r)) [_] Public Assistance payments (section §2-352b(d)) [J Other claim of exempt funds (Explain basis for claim of exemption) (_] Wages* (section 52-361a) [_] 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: LJ Alimony and support other than child support* (section §2-352b(n)) *See Note Regarding Exemption for Wages and Alimony on back/page 2. Signed Date signed ] Telephone number Complete mailing address of Judgment Debtor Subscribed and sworn Date Al (Town) Signed (Notary Public, Commissioner of Superior Court) to before me on : Page 1 of2 te. .4 ® e Instructions To Clerk To Financial Institution or 4. Complete section 2 of this farm and (1) send 2 copies Attach this form to each financial institution execution issued in a civil family matter against a judgment debtor that is a natural person. of this form and the financial institution execution form to the judgment debtor and to any secured party that Deliver the execution along with this form to the judgment creditor is party to a control agreement between the financial requesting the execution. institution and such secured party under article 9 of If judgment debtor completes and returns this form claiming an title 42a pursuant to section 52-367 of the General exemption, enter the appearance of the judgment debtor with address Statutes and (2) mail notice to judgment debtor as set forth on page 1. required by 31CFR212.6 and 212.7 Set matter down for short calendar hearing. Complete section 7 below. 2. If this claim of exemption is returned completed, fill out Send file-stamped copy of this form to judgment debtor and judgment section 4 of this form and mail, within two business days, to the issuing clerk's office at the address of creditor. court indicated on the front side. See additional After hearing, send copy of any order entered to the financial institution. instructions on the financial institution execution form. Note Regarding Exemption For Wages And Alimony withholding for payment of a judgment is the lesser of (1) twenty- The amount of wages and alimony that may be subject to levy or other (2) the amount by which the individual's disposable earnings for that five per cent of the individual's disposable earnings for that weei k, or Standards Act of 1938, un der Section 6(a)(1) of the Fair Labor week exceed forty times the higher of (A) the federal minimum hourly wage 8, in effect at the time the minimum hourly wage under subsection (i) of Section 31-5: U.S.C. tit, 29, Section 206(a)(1), or (B), the state earnings are payable. e earnings" as that part of the eamings of an individual Section 52-350a(4) of the Connecticut General Statutes defines "disposabl income and employment be withheld for payment of federal remaining after the deduction from those earnings of amounts require .d to ons, union dues and initiation fees, group life insurance premiums, health insurance premiums and taxes, normal retirement contributi federal tax levies. Section 5 — Proper Officer Must Complete This Section Telephone number Name and title of proper officer Dale of service an financial institution se claim form) Section 6 — (To be completed by financial institution upon return of exemption Date mailed to court Name of financial institution ‘Telephone number Date claim received a “Section 7 — Notice To Judgment Debtor And Judgment Creditor date the exemption claim form was received by the financial The assets in dispute are being held for (1) forty-five day: 5 from the institution designated on the front of this form or (2) untit | dispositio n is ordered by the court at a hearing to be held at short calendar on the date set forth below, whichever occurs earlier. Date ofhearing Time of hearing Liam. Courtroom Lhem ADA NOTICE Act (ADA). If you need a reasonable The Judicial Bran: ch of the State of Connecticut complies with the Americans with Disabilities contact person listed at www jud.ct.gov/ADA accommodation in accordance with the ADA, contact a court clerk ar an ADA = Date signed “Bigned (Assistan . a scsi Order this claim, hereby orders that The Court/Magistrate, having held a hearing to determine the issues raised by “Bythe Coun (Name of Judge/Family Support ‘Magistrate/Magistrate) o Judge [_] FSM [77 Magistrate Date signed Signed (ludge/Family Support Tagistrate/Magistrate/Assistant Clerk) ee s = si JD-CV-24A (page 2) Rev. 2-15 Page 2 of 2