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FINANCIAL INSTITUTION EXECUTION
PROCEEDI S - JUDGMENT DEBTOR
STATE OF CONNECTICUT
SUPERIOR COURT
Ee
*AP ABA*
WHO IS A NATURAL PERSON, www.jud.ct.gov
APPLICATION
JD-CV-24 Rav.
AND EXECUTION
2-15
(See page 2 for instructions to financial institution (OEE
"EXISSUE*
C.GS. §§ 52-356b, 52-367b and ADA Notice)
PA.14-7, 14-9 Instructions- Clerk
Instructions
- Judgment Creditor Or Attorney
1. Check the file to ensure that the information provided
ype or print legibly.
‘prepare original and 2 copies. ‘on the applicationis compet.
pmplete
3. Complete sovdon tof Exemption Clalm Form, JD-C\ ja and attach
to this form. 2 Sign original execution.
for file.
‘Address
of court [x]Ju district Geogray number
50 FIE LD ST, TORRINGTON, CT 06790 Housing session _[_] number, ULI-cv-21-6028403-S
‘Name aid mailing address of Judgment Creditor or Attomey (To be completed by Judgment Creditor)
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REVELEY WILLIAM G. & ASSOCIATES LLC
P.O. BOX 657
VERNON, CT 06066
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s)
Name(s) and address(es) of Judgment Credi
HOP ENERGY LLC DBA MERCU! RY ENERGY
D OAK LANE, WHITE PLAINS, NY 10604
Name(s) and address(es) of Judgment Debtor(s)
STEPHANIE GREE!
106 \ |GUSTA ST, OAKVILLE, CT 06779
Date of judgment 4. Amount
of judgment (include, where applicabie, 2, Amount
of costs ‘3, Amount Judgment,
costs and fees (Add
7 and 2)
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09/23/2021 $1,684.53 attomey’s fees) $102.40 $1,786.9:
4 Total amount pas (it any) $-Total amount unpald (Subtract 4 from 3) 6. Application fee for financial institution ‘execution (if not waived by the court)
$0.00| $1,786.93 $105.00
7 Applicaion fe0s pald for prior executions on this judgment 6. Other court ordered postjudgment
costs and fees: @.Total of tems 5, 6,7 and 8
$0.00) $60.00 $1,951.93
| ‘Check if applicable
postjudgment
interest was ordered by the court
1s this judgment arising out of services rendered ata hospital?_| [x] No 1 Yes
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It this ig a judgment arising out of services rendered at a hospital, hasa stay of
" pursuant to an installment payment a financial institution execution been [KI [No Yes
tta sta of a financtal institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order?
On Yes (Specify): DEBTOR HAS MADE NO PAYMENTS
‘Sign Date signed ‘Telephone number
HitetAM G REVELEY 11/22/2021 8608720686
Financial Institution Execution
To any proper officer,
‘Whereas on Said Date of Judgment the above-nams ed Judgment Creditor(s) recovered judgment against the above-named Judgment Debtor(s) before the above-
named court {or the amount of judgment, costs and fees stated above, as appears of record, whereof execution remains to be Hone.
These are, th , by authority of the state of Connecticut to command you:
Within seven|c 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 isnot within your county and such financial Institution has one or more branch offices within your county, upon an @mployee of such a branch office, such
for
employee ai \d such branch office having been designated by the financial institution in accordance with regulations adopted by the commissioner of banking,
payment to pursuant to section 52-367b(b) of the General Statutesof any nonexempt debt due sald Judgment Debtor(s), Which sum shall not exceed the total
unpaid judgment, costs and fees as stated above, plus postjudgment interestas ordered by the court, if applicable, plus the af iplication fee and other court ordered:
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postjudgment costs and fees and your own fee. Afier having made such demand you are directed to serve a true and attested|copy of this execution, together with the
attached davit and exemption claim form, with your doings endorsed thereon, with the financial institution officer upon whorn such demand was made. Said sum
‘shall be. ived by you and applied on this execution In accordance with the provisions of section 52-367b of the General ‘Statutes. You'shail not serve more than one
financial inst tion execution per judgment debtor at a time, including copies thereof. After service of an execution on one For Court Use Only
financial ins tion, you shall not serve the same execution ora copy thereof upon another financial institution until receiving
confirmation 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 th 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
er a ke or (°
required by federal law). If no such de ade, you may subsequently serve the same execution or a copy thereof
upon such in istitution, provided the execution has ‘expired or otherwise become unenforceable.
Hereof fail|not, and make due V/. is writ with your doings thereon, according to law.
Staned (Assistant lark)
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FINANGIAL INS" TION EXECUTION PROCEEDINGS
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OTE: The provisions of section 52-367b, as amended from time to time, take precedence o' these instructions.
Instructi ns To Financial Institution Upon Receipt Of A Financial Institution Execution
., When Jui Igment Debtor Is A Natural Person
1. If any fun is al re removed from the judgment debtor's account pursuant to subsection (c) of section
§2-367b of the General Statutes,
complete i n Il 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 secut red party that is a party to a control greement between you and such
secured p: under article 9 of title 42a of the General Statutes, postage pre-paid, at the last known ad ress of the judgment debtor and
of any h secured party with respect to the affected accounts on the records of your institution and (2) mail notice to the judgment
debtor as uired by 31CFR212.6 and 212.7.
Remove 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 In: itution Execution and other court
ordered pt judgment costs or fees and the serving officer's fee, before your midnight deadline, as d ined in section 42a-4-104 of the
General tatutes. If an electronic direct deposit is readily identifiable as exempt federal veterans’ benefits, Social Security benefits,
including,| ut not limited to, retirement, survivors’ and disability benefits, supplemental security income benefits, exempt benefits paid by
the | Railroad Retirement Board or the federal Office of Personnel Management, unemployment compensation benefits exempt
under si dtion 52-352b of the Connecticut General Statutes, or child support payments processed and ceived pursuant to Title IV-D of
the Social Security Act were made to the judgment debtor's account during the look-back period of ei ler the sixty-day period preceding
the date that the execution was served on you, or, with regard to federal benefits, such greater period fequired by federal law then you
shall leay le the lesser of the account balance or one thousand dollars in the judgment debtor's account, provided nothing in this
subset shail be construed to limit your right or obligation to remove such funds from the judgment debtor's account if required by any
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other pi \ ion of law or by a court order. The judgment debtor shall have full and customary access {o such funds left in the judgment
debtor's count. 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! ction (a) of section 52-367b
of theGe} eral Statutes or under any other provision of state or federal law, or the right of a judgment debtor to claim such exemption.
Nothing fierein 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.
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the amount removed from the judgment debtor's account pursuant to this execution for fifteen days from the date you mail
3. You must
i hold
the copi of this form and the Exemption Claim Form to the judgment debtor and any secured party. During such fifteen day period you
must not the officer serving this execution.
IF the judé ent debtor retums 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 i such deposit account, you must,
within ® 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
regardit J 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 judgt nent debtor's account.
if you do Inot receive a claim of exemption or secured party claim notice within fifteen days of the mailing to the judgment debtor and any
secured ty of the execution and Exemption Claim Form you must, upon demand, forthwith p the serving officer the amount
removed from the judgment debtor's account.
Ifno , tion claim or secured party claim notice is filed or if the court orders you to pay the servit g officer an amount removed from
the judgn nt 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 the efor to the judgement creditor(s) named in the execution for the amount of nonexempt monies which you fail or refuse to pay
over. If exemption claim is filed or if the court orders you to pay the serving officer an amount removed from the judgment debtor's
account 4 t 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 e to pay over, excluding funds of
up to one thousand dollars which you in good faith allowed the judgment debtor to access pursuant @ subsection (c) of section 52-367b
i
of the General Statutes.
7. f you pay
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exempt monies from the account of the judgment debtor contrary to these instructions, or e provisions of section 52-367b of
the Gen 5 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 p (id and you shail refund or waive
any charges of fees by you, including, but not limited to, dishonored check fees, overdraft fees or mini jum balance service charges and
legal prd s 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
Disabtities
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.gow/ADA.
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SD-CV-24 Luipage 2) Rev. 2-45 Page 2 of 2
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EXEMPTION CLAIM FORM STATE OF CONNECTICUT
FINANCIAL.ct, INSTITUTION EXECUTION SWPERIOR COURT
JO-CV-24A Ri
CGS. Srcbe() 23ata, §2-350a, 52-352b, 52-3614, SEE INSTRUCTIONS ON BACKIPAGE 2 www. jud.ct.gov
52-367, 29 U.S|C. 206(a)(1)
Name and address of Judgment Debtor or Attomey
(To bo completed by judgmentcreditor or attorney)
For court
use only
To: MXMPEX
STEPHANIE GREEN
106 AUGUSTA ST
OAKVILLE, CT 06779
aE
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Section 1|— (To be completed by judgment creditor)
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Geographical Name and address of Court (Number, Street, Town and Zip Code)
Judicial Housing
El bistict LD session OO Nea
Number 50 FIELD ST, TORRINGTON, CT 06790
‘Namo
of case fame of Judgment Dabtor jocket
HOP ENERGY LLC DBA MERCURY ENERGY STEPHANIE GREEN LLI-CV-21-6028403-S
V. GREEN, STEPHANIE
Section z= (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 (0 be ratumed jate of mailing to Judgment Debtor
Last4 Digits of the Account Number(s) “Amount removed pursuantto execution ‘Amount and typo of readily |dentiiable exempt funds not removed
:
L] Additio al 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 it jatitution named above. To comply with this execution, the financial institution has removed He amount of money indicated
above from ithe account(s) listed above.
THE MONEY IN YOUR ACCOUNT(S) MAY BE EXEMPT FROM EXECUTION- The money in your agcount(s) may be protected from
execution state statutes or by other laws or regulations of Connecticut or of the United States. A checklist and a description of the most
common e> xemptions established by law are set forth below.
HOW TQ CLAIM AN EXEMPTION ESTABLISHED BY LAW. If you wish to claim that the money in ygur account(s) is exempt by law
from execut tion, 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
frot 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 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 jucigment debtor named above, claim and certify under the penalty of false statement thatithe money In the above account
is exempt | y law from execution as follows: ("X" all that apply to the funds contained in this account)
| [J Private pension, trust, retirenjent, or medical savings
OO so i
| Security benefits (section 52-352b(g))
oO Unerpployment benefits (section 52-352b(a)) account payments (sections 12-32. 1a, 52-352b(m))
L] Wort ‘er's Compensation benefits (section 52-352b(g)) C Health or disability insurance| payments (section 52-352b(e))
n's benefits (section 52-352b(9)) (G1 An amount in the bank not to|exceed $1000 (section 52-352b(r))
oO Publ Assistance payments (section 52-352b(d)) LJ Other claim of exempt funds | (Explain basis for clelm of exemption):
Wag s earned by a public assistance recipient under an
incentive eamings or similar program (section 52-352b(d))
Oo Cour t-ordered child support payments (section 52-352b(h)) Amount claimed to be exempt
oO Alimony and support other than child support* (section 52-352b(n)) if less than the entire amount:
*See|Note Regarding Exemption for Alimony and Support on back/page 2.
‘Signed
| Date signed ‘Telephone number
‘Complete mailing address of Judgment Debtor
Subscribed and sworn Date ‘At (Town) ‘Signed (Notary Public, Commissioner
of Superior Court)
to before me on
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Instructions
To Financial Institution To Cle
1. Complete section
2 of this form and (1) send 2 copies 4. Attach this form to each financial institution execution issued in a civil or
of thisfo and the financial institution execution form family matter against a judgment det r that is a natural person.
to the judgment debtor and to any secured party that is Deliver the execution along with this form to the judgment creditor
party to a control agreement between the financial requesting the execution.
Institution and such secured party under article 9 of Ifjudgment debtor completes and returns this form claiming an
title 42a rsuant to section 52-367b of the General exemption, enter the appearance of the judgment debtor with address
Statutesjand (2) mall notice to judgment debtor as set forth on page 1.
Tequired|by 31CFR212.6 and 212.7. Set matter down for short calendar hearing
2. If this claim of exemption is returned completed, fill out Complete section 7 below.
section 6 of this form and mail, within two business Send file-stamped copy of this form to judgment debtor and judgment
days, tolthe issuing clerk's office at the address of creditor.
court indicated on the front side. See additional 7. After hearing, send copy of any order entered to the financial institution.
instru ions on the financial institution execution form.
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Note Reg: ding Exemption for Alimony and Support
Alimony an, Support, other than child support, are exempt only to the following extent:
The amount of alimony and support, other than child support, that may be subject to levy
or other withholding for payment of a judgment is
the lesser of (1) twenty-five percent of the individual's disposable earnings for that week, or (2) the amount by which the individual's
disposable ¢ ings for that week exceedforty times the higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair
Labor Standards Act of 1938, U.S.C. Title 29, Section 206(a)(1), or (B), the stata minimum hourly wage under subsection
(i) of Section
31-58, in eftect at the time the eamings are payable.
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Section 52-3 50a(4) of the Connecticut General Statutes defines “disposable earings" as that part of the eamings of an individual remaining
after the det duction from those eamings of amounts required to be withheld for payment of federal income'and employment taxes, normal
retirement ‘pnributons union dues and initiation fees, group life insurance premiums, health insurance premiums and federal tax levies,
Section s— Proper Officer Must Complete This Section
‘Name and fie
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 recdived ‘Date mailed
to court ‘Name of financial institution Telephone number
Section { — Notice To Judgment Debtor And Judgment Creditor
‘The asset! “ 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 a.m. Courtroom
p.m.
‘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 Judga/ramlly Support Magistrate/Magistrate)
DD sudge (1 Fsm (1) Magistrate
‘Signed (Judge/Family Support Magistrate/Magistrate/Assistant Clerk) Date signed
ADA NOTICE
The Jluical Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable
accorimodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www-jud.ct.gov/ADA.
ID-CV-24A aia 2) Rev. 1-17 Page
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FINANCIAL INSTITUTION EXECUTION PROCEEDI S - JUDGMENT DEBTOR STATE OF CONNECTICUT SUPERIOR COURT Ee *AP ABA* WHO IS A NATURAL PERSON, www.jud.ct.gov APPLICATION JD-CV-24 Rav. AND EXECUTION 2-15 (See page 2 for instructions to financial institution (OEE "EXISSUE* C.GS. §§ 52-356b, 52-367b and ADA Notice) PA.14-7, 14-9 Instructions- Clerk Instructions - Judgment Creditor Or Attorney 1. Check the file to ensure that the information provided ype or print legibly. ‘prepare original and 2 copies. ‘on the applicationis compet. pmplete 3. Complete sovdon tof Exemption Clalm Form, JD-C\ ja and attach to this form. 2 Sign original execution. for file. ‘Address of court [x]Ju district Geogray number 50 FIE LD ST, TORRINGTON, CT 06790 Housing session _[_] number, ULI-cv-21-6028403-S ‘Name aid mailing address of Judgment Creditor or Attomey (To be completed by Judgment Creditor) Ir 4 REVELEY WILLIAM G. & ASSOCIATES LLC P.O. BOX 657 VERNON, CT 06066 L s) Name(s) and address(es) of Judgment Credi HOP ENERGY LLC DBA MERCU! RY ENERGY D OAK LANE, WHITE PLAINS, NY 10604 Name(s) and address(es) of Judgment Debtor(s) STEPHANIE GREE! 106 \ |GUSTA ST, OAKVILLE, CT 06779 Date of judgment 4. Amount of judgment (include, where applicabie, 2, Amount of costs ‘3, Amount Judgment, costs and fees (Add 7 and 2) \ 09/23/2021 $1,684.53 attomey’s fees) $102.40 $1,786.9: 4 Total amount pas (it any) $-Total amount unpald (Subtract 4 from 3) 6. Application fee for financial institution ‘execution (if not waived by the court) $0.00| $1,786.93 $105.00 7 Applicaion fe0s pald for prior executions on this judgment 6. Other court ordered postjudgment costs and fees: @.Total of tems 5, 6,7 and 8 $0.00) $60.00 $1,951.93 | ‘Check if applicable postjudgment interest was ordered by the court 1s this judgment arising out of services rendered ata hospital?_| [x] No 1 Yes | It this ig a judgment arising out of services rendered at a hospital, hasa stay of " pursuant to an installment payment a financial institution execution been [KI [No Yes tta sta of a financtal institution execution has been entered, has the Judgment Debtor defaulted on an installment payment order? On Yes (Specify): DEBTOR HAS MADE NO PAYMENTS ‘Sign Date signed ‘Telephone number HitetAM G REVELEY 11/22/2021 8608720686 Financial Institution Execution To any proper officer, ‘Whereas on Said Date of Judgment the above-nams ed Judgment Creditor(s) recovered judgment against the above-named Judgment Debtor(s) before the above- named court {or the amount of judgment, costs and fees stated above, as appears of record, whereof execution remains to be Hone. These are, th , by authority of the state of Connecticut to command you: Within seven|c 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 isnot within your county and such financial Institution has one or more branch offices within your county, upon an @mployee of such a branch office, such for employee ai \d such branch office having been designated by the financial institution in accordance with regulations adopted by the commissioner of banking, payment to pursuant to section 52-367b(b) of the General Statutesof any nonexempt debt due sald Judgment Debtor(s), Which sum shall not exceed the total unpaid judgment, costs and fees as stated above, plus postjudgment interestas ordered by the court, if applicable, plus the af iplication fee and other court ordered: ") postjudgment costs and fees and your own fee. Afier having made such demand you are directed to serve a true and attested|copy of this execution, together with the attached davit and exemption claim form, with your doings endorsed thereon, with the financial institution officer upon whorn such demand was made. Said sum ‘shall be. ived by you and applied on this execution In accordance with the provisions of section 52-367b of the General ‘Statutes. You'shail not serve more than one financial inst tion execution per judgment debtor at a time, including copies thereof. After service of an execution on one For Court Use Only financial ins tion, you shall not serve the same execution ora copy thereof upon another financial institution until receiving confirmation 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 th 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 er a ke or (° required by federal law). If no such de ade, you may subsequently serve the same execution or a copy thereof upon such in istitution, provided the execution has ‘expired or otherwise become unenforceable. Hereof fail|not, and make due V/. is writ with your doings thereon, according to law. Staned (Assistant lark) | | 2 Page 1 of 2 fiYe 4Y FINANGIAL INS" TION EXECUTION PROCEEDINGS | | OTE: The provisions of section 52-367b, as amended from time to time, take precedence o' these instructions. Instructi ns To Financial Institution Upon Receipt Of A Financial Institution Execution ., When Jui Igment Debtor Is A Natural Person 1. If any fun is al re removed from the judgment debtor's account pursuant to subsection (c) of section §2-367b of the General Statutes, complete i n Il 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 secut red party that is a party to a control greement between you and such secured p: under article 9 of title 42a of the General Statutes, postage pre-paid, at the last known ad ress of the judgment debtor and of any h secured party with respect to the affected accounts on the records of your institution and (2) mail notice to the judgment debtor as uired by 31CFR212.6 and 212.7. Remove 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 In: itution Execution and other court ordered pt judgment costs or fees and the serving officer's fee, before your midnight deadline, as d ined in section 42a-4-104 of the General tatutes. If an electronic direct deposit is readily identifiable as exempt federal veterans’ benefits, Social Security benefits, including,| ut not limited to, retirement, survivors’ and disability benefits, supplemental security income benefits, exempt benefits paid by the | Railroad Retirement Board or the federal Office of Personnel Management, unemployment compensation benefits exempt under si dtion 52-352b of the Connecticut General Statutes, or child support payments processed and ceived pursuant to Title IV-D of the Social Security Act were made to the judgment debtor's account during the look-back period of ei ler the sixty-day period preceding the date that the execution was served on you, or, with regard to federal benefits, such greater period fequired by federal law then you shall leay le the lesser of the account balance or one thousand dollars in the judgment debtor's account, provided nothing in this subset shail be construed to limit your right or obligation to remove such funds from the judgment debtor's account if required by any | other pi \ ion of law or by a court order. The judgment debtor shall have full and customary access {o such funds left in the judgment debtor's count. 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! ction (a) of section 52-367b of theGe} eral Statutes or under any other provision of state or federal law, or the right of a judgment debtor to claim such exemption. Nothing fierein 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. | the amount removed from the judgment debtor's account pursuant to this execution for fifteen days from the date you mail 3. You must i hold the copi of this form and the Exemption Claim Form to the judgment debtor and any secured party. During such fifteen day period you must not the officer serving this execution. IF the judé ent debtor retums 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 i such deposit account, you must, within ® 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 regardit J 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 judgt nent debtor's account. if you do Inot receive a claim of exemption or secured party claim notice within fifteen days of the mailing to the judgment debtor and any secured ty of the execution and Exemption Claim Form you must, upon demand, forthwith p the serving officer the amount removed from the judgment debtor's account. Ifno , tion claim or secured party claim notice is filed or if the court orders you to pay the servit g officer an amount removed from the judgn nt 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 the efor to the judgement creditor(s) named in the execution for the amount of nonexempt monies which you fail or refuse to pay over. If exemption claim is filed or if the court orders you to pay the serving officer an amount removed from the judgment debtor's account 4 t 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 e to pay over, excluding funds of up to one thousand dollars which you in good faith allowed the judgment debtor to access pursuant @ subsection (c) of section 52-367b i of the General Statutes. 7. f you pay | exempt monies from the account of the judgment debtor contrary to these instructions, or e provisions of section 52-367b of the Gen 5 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 p (id and you shail refund or waive any charges of fees by you, including, but not limited to, dishonored check fees, overdraft fees or mini jum balance service charges and legal prd s 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 Disabtities 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.gow/ADA. | | SD-CV-24 Luipage 2) Rev. 2-45 Page 2 of 2 | 1 | 4" | EXEMPTION CLAIM FORM STATE OF CONNECTICUT FINANCIAL.ct, INSTITUTION EXECUTION SWPERIOR COURT JO-CV-24A Ri CGS. Srcbe() 23ata, §2-350a, 52-352b, 52-3614, SEE INSTRUCTIONS ON BACKIPAGE 2 www. jud.ct.gov 52-367, 29 U.S|C. 206(a)(1) Name and address of Judgment Debtor or Attomey (To bo completed by judgmentcreditor or attorney) For court use only To: MXMPEX STEPHANIE GREEN 106 AUGUSTA ST OAKVILLE, CT 06779 aE L Section 1|— (To be completed by judgment creditor) | Geographical Name and address of Court (Number, Street, Town and Zip Code) Judicial Housing El bistict LD session OO Nea Number 50 FIELD ST, TORRINGTON, CT 06790 ‘Namo of case fame of Judgment Dabtor jocket HOP ENERGY LLC DBA MERCURY ENERGY STEPHANIE GREEN LLI-CV-21-6028403-S V. GREEN, STEPHANIE Section z= (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 (0 be ratumed jate of mailing to Judgment Debtor Last4 Digits of the Account Number(s) “Amount removed pursuantto execution ‘Amount and typo of readily |dentiiable exempt funds not removed : L] Additio al 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 it jatitution named above. To comply with this execution, the financial institution has removed He amount of money indicated above from ithe account(s) listed above. THE MONEY IN YOUR ACCOUNT(S) MAY BE EXEMPT FROM EXECUTION- The money in your agcount(s) may be protected from execution state statutes or by other laws or regulations of Connecticut or of the United States. A checklist and a description of the most common e> xemptions established by law are set forth below. HOW TQ CLAIM AN EXEMPTION ESTABLISHED BY LAW. If you wish to claim that the money in ygur account(s) is exempt by law from execut tion, 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 frot 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 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 jucigment debtor named above, claim and certify under the penalty of false statement thatithe money In the above account is exempt | y law from execution as follows: ("X" all that apply to the funds contained in this account) | [J Private pension, trust, retirenjent, or medical savings OO so i | Security benefits (section 52-352b(g)) oO Unerpployment benefits (section 52-352b(a)) account payments (sections 12-32. 1a, 52-352b(m)) L] Wort ‘er's Compensation benefits (section 52-352b(g)) C Health or disability insurance| payments (section 52-352b(e)) n's benefits (section 52-352b(9)) (G1 An amount in the bank not to|exceed $1000 (section 52-352b(r)) oO Publ Assistance payments (section 52-352b(d)) LJ Other claim of exempt funds | (Explain basis for clelm of exemption): Wag s earned by a public assistance recipient under an incentive eamings or similar program (section 52-352b(d)) Oo Cour t-ordered child support payments (section 52-352b(h)) Amount claimed to be exempt oO Alimony and support other than child support* (section 52-352b(n)) if less than the entire amount: *See|Note Regarding Exemption for Alimony and Support on back/page 2. ‘Signed | Date signed ‘Telephone number ‘Complete mailing address of Judgment Debtor Subscribed and sworn Date ‘At (Town) ‘Signed (Notary Public, Commissioner of Superior Court) to before me on | Page 1 of2 | I } Instructions To Financial Institution To Cle 1. Complete section 2 of this form and (1) send 2 copies 4. Attach this form to each financial institution execution issued in a civil or of thisfo and the financial institution execution form family matter against a judgment det r that is a natural person. to the judgment debtor and to any secured party that is Deliver the execution along with this form to the judgment creditor party to a control agreement between the financial requesting the execution. Institution and such secured party under article 9 of Ifjudgment debtor completes and returns this form claiming an title 42a rsuant to section 52-367b of the General exemption, enter the appearance of the judgment debtor with address Statutesjand (2) mall notice to judgment debtor as set forth on page 1. Tequired|by 31CFR212.6 and 212.7. Set matter down for short calendar hearing 2. If this claim of exemption is returned completed, fill out Complete section 7 below. section 6 of this form and mail, within two business Send file-stamped copy of this form to judgment debtor and judgment days, tolthe issuing clerk's office at the address of creditor. court indicated on the front side. See additional 7. After hearing, send copy of any order entered to the financial institution. instru ions on the financial institution execution form. i Note Reg: ding Exemption for Alimony and Support Alimony an, Support, other than child support, are exempt only to the following extent: The amount of alimony and support, other than child support, that may be subject to levy or other withholding for payment of a judgment is the lesser of (1) twenty-five percent of the individual's disposable earnings for that week, or (2) the amount by which the individual's disposable ¢ ings for that week exceedforty times the higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair Labor Standards Act of 1938, U.S.C. Title 29, Section 206(a)(1), or (B), the stata minimum hourly wage under subsection (i) of Section 31-58, in eftect at the time the eamings are payable. | Section 52-3 50a(4) of the Connecticut General Statutes defines “disposable earings" as that part of the eamings of an individual remaining after the det duction from those eamings of amounts required to be withheld for payment of federal income'and employment taxes, normal retirement ‘pnributons union dues and initiation fees, group life insurance premiums, health insurance premiums and federal tax levies, Section s— Proper Officer Must Complete This Section ‘Name and fie 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 recdived ‘Date mailed to court ‘Name of financial institution Telephone number Section { — Notice To Judgment Debtor And Judgment Creditor ‘The asset! “ 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 a.m. Courtroom p.m. ‘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 Judga/ramlly Support Magistrate/Magistrate) DD sudge (1 Fsm (1) Magistrate ‘Signed (Judge/Family Support Magistrate/Magistrate/Assistant Clerk) Date signed ADA NOTICE The Jluical Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accorimodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www-jud.ct.gov/ADA. ID-CV-24A aia 2) Rev. 1-17 Page 2 0f2 || |