Preview
ale
FINANCIAL INSTITUTION EXECUTION @ STATE OF CONNECTICUT e
. PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT
‘WHO IS A NATURAL PERSON, www jud.ct.gov
APPLICATION AND EXECUTION “ .,
SD-CV24 Rev. 2-15 (See page 2 for instructions to financial institution ae
C.GS, §§ 52-356b, 52-3675 and ADA Notice)
PA14-7, 14-0 | .
Instructions - Judgment Craditor Or Attomey Instructions - Clerk
1. Type or’ print fegibly. 1. Chack the file to ensure that the information provided:
2. Complete the application section; prepare original and 2 copies. con the epplication ts correct.
‘and attach to this form. Sign yxacution. ¥10322
3. Complete section 7 of the Exemption Claim Form, JD-«
Present and 4
Name and mailing address tee) ‘or Attomey ee aby ledger! Cod)
fLaw Offices 7
Howard Lee Schiff,P.C.
P/0.Box 260245
E Hartford, CT 06128 0245
Ll, a
Nama(e) and address(es) of Judgment Creditors)
z FIA|CARD SERVICES, N.A.
655|PAPERMILL ROAD NEWARK, DE 19711
Name(s) and address(es) of Judgment Debtor(s)
REBECCA. M MULHARE
206| BAKER RD ROXBURY, CT 06763
Data ofjudgment 7, Amount of judgment (include, whore applicable, | 2 Amount of coats TAmvount of judgment, costs and fees (Add 7 and 2)
6/06/16 $8,589.87 — erpiudament lorast and $437.20 $9,027.07
“Total amount paid (if any) &Total amount unpald (Subtract 4 from 3) | 6. Application fee for financial inetitufion exeautlan (iF nol waived by the court)
$00 $9,027.07 $105.00 .
7, Application feas pald or prior executions an this judgment | 6. Other court ordered postjudgment costs and fees D.Tatal of tems 6, 6, 7 and &
$.00 : $.00 $9,132.07
‘Check applicable
Ts this judgment arising out of services rendered at a hospital? x No = [_] Yes [C7 posgudgment interest was ordered by the court
7
tf this sa Judgment arising out of serdces rendered at a hospital, has asta ofa franca Iattutton execution been) gg or.
entered pursvzant to an Installment payment order? (es
ta stay of a nage! institution execution has heen entered, has the Judgment Debtor defaulted on an installment payment o
No} Yes (Specify):
Signed (u ‘Creditor or Attomey)
Timothy
Date signed Telephone ni
~¢4? 7 (860) 528-9991
Furman
Financial Institution Execution
To any proper Officer,
‘Whereas on said Date of Judgment the above-1 Judgment Craditor(s) recovered judgment against the above-named Judgment Debtor(s) before thé 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 racelpt 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 caunty and such financial Institution has one or mara branch offices within your county, upon an employee of such a branch office, such
employee and such branch office having been designated by the financial Institution in accordance with regulations adopted by the commissioner of banking, for
payment to you pursuant to section 52-367b(0) of the General Statules of any nonexempt debt due said Judgment Debtor(s), which sum shall not exceed the total
Unpaid judgment, costs and fees as stated above, plus postjudgment Interest as ordered by the cour, if applicable, plus the application fee end other court ordered
postjudgment costs and fees and your own fee. After having made such demand you are directed fo serve @ 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 wham such demand was made. Sald sum
shall be received by you and applied on this exacution 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 @ time, including copies there. After service of an execution on one For Court Use Only
financial institution, you shall not serve the sane execution or a copy thereof upon anather financlat institution until receiving
confirmation from the preceding financial insftution that the judgment debtor had ineufficient funds at the preceding financial OFFICE OF THE CLERK
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 tha same execution ar @ SUPERIOR COURT
copy thereof upon|such financial institution if an electronic direct depost trom a realy identifiable source described in ,
section 62 -376b (¢) of the General Statutes was made to the judgment debtor's account within the look-back period 2,
described In section 62 -376b (c) of the General Statues (sixty days or, with regard to federal benefits, such greater period as FEB 08 2017
required by federal law). If no such deposit was made, you may subsequently serve the same execution or a copy thereof
upon such institufion, 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. MO P UTCH CT
Signe: | Date signed —
ae Rel
xB Page (of 2 FINANCIAL INSTITUTION EXECUTION PROCEEDINGS
1/04/17NOTE: 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
If any funds ae removed from the judgment debtor's account pursuant to subsection (c) of section 52-337b of the General Statutes,
complete section tI of the accompanying Exemption Claim Form (JD-CV-24a) and (1) send, forthwith, 2 cop.es 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 titfe 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 @) 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. If an electronic direct deposit is readily identifiable as exempt federal veterans’ benefits, Social Security benefits,
including. but not limited to, retirement, survivors’ and disability benefits, supplemental security income benefits, exempt benefits paid by
the federat Raliroad Retirement Board or the federal Office of Personnel Management, unemployment compensation benefits exempt
under section '62-352b 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
shall leave the fesser of the account balance or one thousand dollars in the judgment debtor's account, provided nathing in this
subsection shall be construed to fimit 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 ieft in the judgment debtor's account pursuant to this
provision. Nothing herein shall alter the exempt status of funds which are exempt from execution under subsection (a) of section 52-367b
of the General Statutes or under any other provision of state or federal law, or the right of a judgment debtor to claim such exemption.
Nothing herein shall be construed to affect any other rights or obligations of the financial institution with regard to the funds in the
judgment debtors account.
3. You must hold the amount removed from the judgment debtor's account pursuant to this execution for fifteen days from the data 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 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 securily interest in such deposit account, you must,
within two | business fae of receipt of such notice, send a copy of such notice to the clerk of the court which issued the execution. You
must ci amount removed from the judgment debtor's account for forty-five days or until a court order is received
ras iti
regardin: funds, whichever occurs earlier. If no order is received within forty-five days of the date you send a copy of
the Exe eninotice of exemption or a secured party claim notice to the clerk of the court, you must return the funds to
the judgment: ‘seboo’s account. vee!
iP a
|. If you do not feceive a claim of exemption or secured party dlaim notice within fifteen days of the mailing to the judgment’ debtor and any
secured party of the execution and Exemption Claim Form you must, upon demand, forthwith pay the serving officer the amount
removed from the Judgment debtor's account.
6. If no exemption claim or secured party claim notice is filed or if the court orders you fo 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 shail be fiable in an action therefor to the judgment debtor for any exempt monies s0 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 shail refund or waive
any charges of fees by you, including, but not fimited 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.
a
ADA NOTICE
‘The Judicial Branch of the State af Connecticut complies with the Americana with
Disabilities Act (ADA). If you nead a reasonable accommodation in accordance with the
ADA, contact a court clerk or an ADA contact person listed at www,jud.¢t.gow/ADA,
ID-CV-24 (back/page 2) Rev. 2-15 Page 2 of 2EXEMPTION CLAIM FORM
FINANCIAL INSTITUTION EXEGUTION SATE oN DEMOR GOuRy
ee wee SUPERIOR COURT
C.G.S, 31-58(j), 52-321a, §2-350a, 52-352b, 52-3614, SEE INSTRUCTIONS ON BACKIPAGE 2 www.jud.cl.gov
52-867b, 29 U.S.C. 206(a}(1)
, Name and address of Judgment Debtor or Attorney
{To be completed by judgment creditor or atfomey)
To: 7 ’
REBECCA M MULHARE cn yios22 (RIENODIY
206 BAKER RD
THIS COMMUNICATION 18
L_: ROXBURY, CT 06783 J FROM A DEBT COLLECTOR
Section 1 — (To be completed by judgment creditor)
"judicial ! Housing ‘Geographical ‘Name and address of Court (Number, Street, Town and Zip Code)
District OO session Number PO BOX 247 LITCHFIELD CT 06759
Nithe of case ‘Name of Judgment Debtor Docket number
FIA CARD SERVICES, Nun REBECCA M MULHARE LLI-€V14-6011161-~S
vs REBECCA M MULHARE
Section 2 — (To be completed by financial institution - see instructions on back/page 2)
‘Name and address of financlal Institution to which exemption claim (if any) Is to be returned Date af malling to Judgment Debtor
Laat 4 Digits of the Account Number(s) ‘Amount removed pursuant to execution ‘Amount and type of readily identifiable exempt funds not removed
D1 Additional sheat(s) attached hereto and made a part hereof (if necessary).
Section 3 —|Notice To Judgment Debtor
As a result of a judgment entered against you, the attached execution has been issued against funds deposited by you In the
financial institution named above. In compliance with this execution, the financial institution has removed the amount of money indicated
above from the account(s) enumerated above.
THE MONEY. IN YOUR ACCOUNT(S) MAY BE EXEMPT FROM EXECUTION - The money in your account(s) may be protected from
execution by state statutes or by other laws or reguiatlans of this state or of the United States. A checklist and a description of the most
common exemptions established by law are set forth below.
HOW TO CLAIM AN EXEMPTION ESTABLISHED BY IAW. If you wish to claim that the money in your account(s) is exempt by law
from execution, you must fill out and sign before a proper official the Affidavit of Claim of Exemption below and mail or deliver this
exemption claim form to the financial Institution at the above address. This form must be received by the financial institution no later than
15 days from the DATE OF MAILING TO THE JUDGMENT DEBTOR indicated above.
Upon receipt.of this form the financial institution will forward it to the Superior Court and the court clerk will notify you and the judgment
creditar 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)
CO Social Security benefits (section 52-352b(g)) (C] Private pension, trust, retirement, or medical savings
QO Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, $2-352b(m))
(J Worker's|Compensation benefits (section 52-352b(g)) (CZ Health or disability insurance payments (section 52-352b(e))
oO Veteran's benefits (section 52-352b(g)) [_] An amount in the bank not to exceed $1000 (section 52-352b(r))
(] Public Assistance payments (section 52-352b(d)) LJ Other claim of exempt funds (Explein basis for claim of exemption):
LL] Wages* {section 52-361a)
(LO Wages eamed by a public assistance recipient under an
incentive, eamings or similar program (section 52-352b(d)) Amount claimed to be exempt
Ol Courtordered child support payments (section 52-352b(h)) if less than the entire amount:
Oo Alimony and support other than child support* (section 52-352b(n))
*See Note Regarding Exemption for Wages and Alimony on back/page 2.
Signed + Date signed “Telephone number
Complete mailing address of Judgment Debtor
Subseribed and sworn | ate At (Tawny ‘Slanad (Notary Publio, Commissioner of Superior Cour)
to before me on:
Page 1 of 2instructions
To Financial tnstitution
4. Complete section 2 of this form and (1) send 2 copies
of this form and the financial institution execution form
to the judgment debtor and to any secured party that
is party to a control agreement between the financial
institution and such secured party under article 9 of
title 42a pursuant to section 52-367b of the General
Statutes and (2) mail notice to judgment debtor as
required by 31CFR212.6 and 212.7.
. If this claim of exemption is returned completed, fill out
section 4 of this form and mail, within two business
days, to the issuing clerk's office at the address of
court indicated on the front side. See additional
instructions on the financial institution execution form.
w
To Clerk
1. Attach this form to each financial institution execution issued in a civil or
family matter against a judgment debtor that is a natural person.
2. Deliver the execution along with this form to the judgment creditor
requesting the execution.
3, if judgment debtor completes and returns this form claiming an
exemption, enter the appearance of the judgment debtor with address
set forth on page 1.
4, Set matter down for short calendar hearing.
5. Complete section 7 below.
6. Send file-stamped copy of this form to judgment debtor and judgment
craditor,
T. After hearing, send copy of any order entered to the financial institution.
Note Regarding Exemption For Wages And Alimony
The amount of wages and alimony that may be subject to levy or other withholding for payment of a judgment is the lesser of (1) twenty-
five per cent of the individual's disposable earings for that week, or (2) the amount by which the individual's disposable eamings for that
week exceed forty times the higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair Labor Standards Act of 1938,
U.S.C. tit, 29, Section 206(a}(1), or (B), the state minimum hourly wage under subsection (i) of Section 31-58, in offect at the time the
earnings are payable.
Section 52-350a(4) of the Connecticut General Statutes defines "disposable earings" 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 retirament 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 tile 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)
Dale claim received | Date mailed to cour:
"Name of financial Institution
‘Telephone number
Section 7 — Notice To Judgment Debtor And Judgment Creditor
The assets in dis pute 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) untit 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 am. ‘Courtroom
[p.m
ADA NOTICE
The Judicial Branch of the State of Connecticut complie:
accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www,jud.ct.gaw/ADA.
s with the Americans with Disabilities Act (ADA). If you need a reasonable
Signed (Assistant Clerk)
‘Date signed
Order '
The CourtiMagistrate, having held a hearing to determine the issues raised by this claim, hereby orders that:
|
By the Count (Namie of Jidge/Famiy Support Magistrate/Magistrate)
Signed (Judge/Family Suppor Magistvata/Magisirate/Assistant Clerk)
(1 Fsm
[_] Magistrate
JD-CV-24A (page 2) Rev. 2-15
Preview
ale FINANCIAL INSTITUTION EXECUTION @ STATE OF CONNECTICUT e . PROCEEDINGS - JUDGMENT DEBTOR SUPERIOR COURT ‘WHO IS A NATURAL PERSON, www jud.ct.gov APPLICATION AND EXECUTION “ ., SD-CV24 Rev. 2-15 (See page 2 for instructions to financial institution ae C.GS, §§ 52-356b, 52-3675 and ADA Notice) PA14-7, 14-0 | . Instructions - Judgment Craditor Or Attomey Instructions - Clerk 1. Type or’ print fegibly. 1. Chack the file to ensure that the information provided: 2. Complete the application section; prepare original and 2 copies. con the epplication ts correct. ‘and attach to this form. Sign yxacution. ¥10322 3. Complete section 7 of the Exemption Claim Form, JD-« Present and 4 Name and mailing address tee) ‘or Attomey ee aby ledger! Cod) fLaw Offices 7 Howard Lee Schiff,P.C. P/0.Box 260245 E Hartford, CT 06128 0245 Ll, a Nama(e) and address(es) of Judgment Creditors) z FIA|CARD SERVICES, N.A. 655|PAPERMILL ROAD NEWARK, DE 19711 Name(s) and address(es) of Judgment Debtor(s) REBECCA. M MULHARE 206| BAKER RD ROXBURY, CT 06763 Data ofjudgment 7, Amount of judgment (include, whore applicable, | 2 Amount of coats TAmvount of judgment, costs and fees (Add 7 and 2) 6/06/16 $8,589.87 — erpiudament lorast and $437.20 $9,027.07 “Total amount paid (if any) &Total amount unpald (Subtract 4 from 3) | 6. Application fee for financial inetitufion exeautlan (iF nol waived by the court) $00 $9,027.07 $105.00 . 7, Application feas pald or prior executions an this judgment | 6. Other court ordered postjudgment costs and fees D.Tatal of tems 6, 6, 7 and & $.00 : $.00 $9,132.07 ‘Check applicable Ts this judgment arising out of services rendered at a hospital? x No = [_] Yes [C7 posgudgment interest was ordered by the court 7 tf this sa Judgment arising out of serdces rendered at a hospital, has asta ofa franca Iattutton execution been) gg or. entered pursvzant to an Installment payment order? (es ta stay of a nage! institution execution has heen entered, has the Judgment Debtor defaulted on an installment payment o No} Yes (Specify): Signed (u ‘Creditor or Attomey) Timothy Date signed Telephone ni ~¢4? 7 (860) 528-9991 Furman Financial Institution Execution To any proper Officer, ‘Whereas on said Date of Judgment the above-1 Judgment Craditor(s) recovered judgment against the above-named Judgment Debtor(s) before thé 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 racelpt 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 caunty and such financial Institution has one or mara branch offices within your county, upon an employee of such a branch office, such employee and such branch office having been designated by the financial Institution in accordance with regulations adopted by the commissioner of banking, for payment to you pursuant to section 52-367b(0) of the General Statules of any nonexempt debt due said Judgment Debtor(s), which sum shall not exceed the total Unpaid judgment, costs and fees as stated above, plus postjudgment Interest as ordered by the cour, if applicable, plus the application fee end other court ordered postjudgment costs and fees and your own fee. After having made such demand you are directed fo serve @ 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 wham such demand was made. Sald sum shall be received by you and applied on this exacution 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 @ time, including copies there. After service of an execution on one For Court Use Only financial institution, you shall not serve the sane execution or a copy thereof upon anather financlat institution until receiving confirmation from the preceding financial insftution that the judgment debtor had ineufficient funds at the preceding financial OFFICE OF THE CLERK 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 tha same execution ar @ SUPERIOR COURT copy thereof upon|such financial institution if an electronic direct depost trom a realy identifiable source described in , section 62 -376b (¢) of the General Statutes was made to the judgment debtor's account within the look-back period 2, described In section 62 -376b (c) of the General Statues (sixty days or, with regard to federal benefits, such greater period as FEB 08 2017 required by federal law). If no such deposit was made, you may subsequently serve the same execution or a copy thereof upon such institufion, 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. MO P UTCH CT Signe: | Date signed — ae Rel xB Page (of 2 FINANCIAL INSTITUTION EXECUTION PROCEEDINGS 1/04/17NOTE: 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 If any funds ae removed from the judgment debtor's account pursuant to subsection (c) of section 52-337b of the General Statutes, complete section tI of the accompanying Exemption Claim Form (JD-CV-24a) and (1) send, forthwith, 2 cop.es 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 titfe 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 @) 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. If an electronic direct deposit is readily identifiable as exempt federal veterans’ benefits, Social Security benefits, including. but not limited to, retirement, survivors’ and disability benefits, supplemental security income benefits, exempt benefits paid by the federat Raliroad Retirement Board or the federal Office of Personnel Management, unemployment compensation benefits exempt under section '62-352b 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 shall leave the fesser of the account balance or one thousand dollars in the judgment debtor's account, provided nathing in this subsection shall be construed to fimit 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 ieft in the judgment debtor's account pursuant to this provision. Nothing herein shall alter the exempt status of funds which are exempt from execution under subsection (a) of section 52-367b of the General Statutes or under any other provision of state or federal law, or the right of a judgment debtor to claim such exemption. Nothing herein shall be construed to affect any other rights or obligations of the financial institution with regard to the funds in the judgment debtors account. 3. You must hold the amount removed from the judgment debtor's account pursuant to this execution for fifteen days from the data 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 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 securily interest in such deposit account, you must, within two | business fae of receipt of such notice, send a copy of such notice to the clerk of the court which issued the execution. You must ci amount removed from the judgment debtor's account for forty-five days or until a court order is received ras iti regardin: funds, whichever occurs earlier. If no order is received within forty-five days of the date you send a copy of the Exe eninotice of exemption or a secured party claim notice to the clerk of the court, you must return the funds to the judgment: ‘seboo’s account. vee! iP a |. If you do not feceive a claim of exemption or secured party dlaim notice within fifteen days of the mailing to the judgment’ debtor and any secured party of the execution and Exemption Claim Form you must, upon demand, forthwith pay the serving officer the amount removed from the Judgment debtor's account. 6. If no exemption claim or secured party claim notice is filed or if the court orders you fo 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 shail be fiable in an action therefor to the judgment debtor for any exempt monies s0 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 shail refund or waive any charges of fees by you, including, but not fimited 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. a ADA NOTICE ‘The Judicial Branch of the State af Connecticut complies with the Americana with Disabilities Act (ADA). If you nead a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www,jud.¢t.gow/ADA, ID-CV-24 (back/page 2) Rev. 2-15 Page 2 of 2EXEMPTION CLAIM FORM FINANCIAL INSTITUTION EXEGUTION SATE oN DEMOR GOuRy ee wee SUPERIOR COURT C.G.S, 31-58(j), 52-321a, §2-350a, 52-352b, 52-3614, SEE INSTRUCTIONS ON BACKIPAGE 2 www.jud.cl.gov 52-867b, 29 U.S.C. 206(a}(1) , Name and address of Judgment Debtor or Attorney {To be completed by judgment creditor or atfomey) To: 7 ’ REBECCA M MULHARE cn yios22 (RIENODIY 206 BAKER RD THIS COMMUNICATION 18 L_: ROXBURY, CT 06783 J FROM A DEBT COLLECTOR Section 1 — (To be completed by judgment creditor) "judicial ! Housing ‘Geographical ‘Name and address of Court (Number, Street, Town and Zip Code) District OO session Number PO BOX 247 LITCHFIELD CT 06759 Nithe of case ‘Name of Judgment Debtor Docket number FIA CARD SERVICES, Nun REBECCA M MULHARE LLI-€V14-6011161-~S vs REBECCA M MULHARE Section 2 — (To be completed by financial institution - see instructions on back/page 2) ‘Name and address of financlal Institution to which exemption claim (if any) Is to be returned Date af malling to Judgment Debtor Laat 4 Digits of the Account Number(s) ‘Amount removed pursuant to execution ‘Amount and type of readily identifiable exempt funds not removed D1 Additional sheat(s) attached hereto and made a part hereof (if necessary). Section 3 —|Notice To Judgment Debtor As a result of a judgment entered against you, the attached execution has been issued against funds deposited by you In the financial institution named above. In compliance with this execution, the financial institution has removed the amount of money indicated above from the account(s) enumerated above. THE MONEY. IN YOUR ACCOUNT(S) MAY BE EXEMPT FROM EXECUTION - The money in your account(s) may be protected from execution by state statutes or by other laws or reguiatlans of this state or of the United States. A checklist and a description of the most common exemptions established by law are set forth below. HOW TO CLAIM AN EXEMPTION ESTABLISHED BY IAW. If you wish to claim that the money in your account(s) is exempt by law from execution, you must fill out and sign before a proper official the Affidavit of Claim of Exemption below and mail or deliver this exemption claim form to the financial Institution at the above address. This form must be received by the financial institution no later than 15 days from the DATE OF MAILING TO THE JUDGMENT DEBTOR indicated above. Upon receipt.of this form the financial institution will forward it to the Superior Court and the court clerk will notify you and the judgment creditar 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) CO Social Security benefits (section 52-352b(g)) (C] Private pension, trust, retirement, or medical savings QO Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, $2-352b(m)) (J Worker's|Compensation benefits (section 52-352b(g)) (CZ Health or disability insurance payments (section 52-352b(e)) oO Veteran's benefits (section 52-352b(g)) [_] An amount in the bank not to exceed $1000 (section 52-352b(r)) (] Public Assistance payments (section 52-352b(d)) LJ Other claim of exempt funds (Explein basis for claim of exemption): LL] Wages* {section 52-361a) (LO Wages eamed by a public assistance recipient under an incentive, eamings or similar program (section 52-352b(d)) Amount claimed to be exempt Ol Courtordered child support payments (section 52-352b(h)) if less than the entire amount: Oo Alimony and support other than child support* (section 52-352b(n)) *See Note Regarding Exemption for Wages and Alimony on back/page 2. Signed + Date signed “Telephone number Complete mailing address of Judgment Debtor Subseribed and sworn | ate At (Tawny ‘Slanad (Notary Publio, Commissioner of Superior Cour) to before me on: Page 1 of 2instructions To Financial tnstitution 4. Complete section 2 of this form and (1) send 2 copies of this form and the financial institution execution form to the judgment debtor and to any secured party that is party to a control agreement between the financial institution and such secured party under article 9 of title 42a pursuant to section 52-367b of the General Statutes and (2) mail notice to judgment debtor as required by 31CFR212.6 and 212.7. . If this claim of exemption is returned completed, fill out section 4 of this form and mail, within two business days, to the issuing clerk's office at the address of court indicated on the front side. See additional instructions on the financial institution execution form. w To Clerk 1. Attach this form to each financial institution execution issued in a civil or family matter against a judgment debtor that is a natural person. 2. Deliver the execution along with this form to the judgment creditor requesting the execution. 3, if judgment debtor completes and returns this form claiming an exemption, enter the appearance of the judgment debtor with address set forth on page 1. 4, Set matter down for short calendar hearing. 5. Complete section 7 below. 6. Send file-stamped copy of this form to judgment debtor and judgment craditor, T. After hearing, send copy of any order entered to the financial institution. Note Regarding Exemption For Wages And Alimony The amount of wages and alimony that may be subject to levy or other withholding for payment of a judgment is the lesser of (1) twenty- five per cent of the individual's disposable earings for that week, or (2) the amount by which the individual's disposable eamings for that week exceed forty times the higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair Labor Standards Act of 1938, U.S.C. tit, 29, Section 206(a}(1), or (B), the state minimum hourly wage under subsection (i) of Section 31-58, in offect at the time the earnings are payable. Section 52-350a(4) of the Connecticut General Statutes defines "disposable earings" 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 retirament 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 tile 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) Dale claim received | Date mailed to cour: "Name of financial Institution ‘Telephone number Section 7 — Notice To Judgment Debtor And Judgment Creditor The assets in dis pute 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) untit 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 am. ‘Courtroom [p.m ADA NOTICE The Judicial Branch of the State of Connecticut complie: accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www,jud.ct.gaw/ADA. s with the Americans with Disabilities Act (ADA). If you need a reasonable Signed (Assistant Clerk) ‘Date signed Order ' The CourtiMagistrate, having held a hearing to determine the issues raised by this claim, hereby orders that: | By the Count (Namie of Jidge/Famiy Support Magistrate/Magistrate) Signed (Judge/Family Suppor Magistvata/Magisirate/Assistant Clerk) (1 Fsm [_] Magistrate JD-CV-24A (page 2) Rev. 2-15