Sane
`FINANCIAL INSTITUTION EXECUTION PROCEEDINGS
`STAUPERIONcounr Ep
`JUDGMENT DEBTOR WHOIS A NATURAL PERSON,
`APPLICATION AND EXECUTION
`wwwjud.ctgov
`\s
`JD-CV-24 Rev. 11-24
`» §§ 62-366, 62-367b
`.
`(See page 2 forinstructions to financialinstitution andADA Notice)
`Instructions - Judgment Creditor orAttorney
`Instructions - Clerk
`
`*fflingeloctronicaly, combineInfootePOEdoneend aonaoonExecution(frmJO-C¥-24A). 1. Checkthefile to ensure theinformation on thepplicationis correct.
`JD-CV-24A and file the original with the clerk. Keep 1 copyforyourrecords,
`2. Sign originalexecution.
`2. Applications must be accompanied bythe statutory fee set in General Statutes § 62-367.
`3. Upload the original to the file.
`Address of court
`[xX] Judictal District
`«| Docket number
`
`14 West RiverStreet, Milford, Connecticut 06460 [_] Housing Session|AAN-CV-22-6049395-S
`Name and mailing address of Judgment Creditor or Attorney
`(Number, street, town, state, zip code) (To be completed by Judgment Creditor) (Plaintitp
`
`
`
`r
`
`L
`
`Philip H. Monagan
`61 Holmes Avenue
`
`Weterbury,Connecticut06722
`
`TO,
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`|
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`
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`ANA |
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`
`
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`ame(s) and address(es) of Judgment Creditor(s) (Party to whom moneyis awed) (Number, street, town, zip code)
`Connecticut Oral & Maxillofacial Surgery Centers, PC
`323 Main Street, West Haven, Connecticut 06516
`
`Name(s) and address(es) of Judgment Debtor(s) (Party who owes money) (Number, street,
`Adrianna M. Davis
`466 Second Avenue, West Haven, Connecticut 06516
`
`fown, zip code)
`
`2. Amount of costs and fees|3. Total amount of judgment, costs and fees (Add 1 and 3
`$104.90
`$4,514.30
`6. Application fee for financial
`institution execution (ifnot waived by the court)
`$105.00
`8. Other court ordered postjudgmient costs and fees
`:
`
`Application
`
`
` $0.00
`j
`sng
`3
`No
`(]
`[[] Postiudomentinterestwas
`
`Is this judgment arising out of services rendered atahospital?........ No Yes
`
`
`
`
`ifyes above, has a stay of a financial institution execution been
`ordered by the court
`entered pursuant to an installment payment order? ..............0.0+-« LJ No
`[) Yes
`Ifa stay of a financial institution execution has been entered, has the
`Judgment Debtor gefa goon n installmentpaymentorder? ........ [No Ex] Yes (Specify: 1, .aymentshave been made
`<—zZ
`a_i ewan
`203-754.7083
`bont money Is owed) Date signed[Telephone number
`Exeetition
`
`
`
`Finandialnstitution
`To any proper Offiéér,
`By authority.of
`th {StategrCo nnecticut, and pursuant to General Statutes § 52-367b you are ordered as follows: Within 7 days, make demand for
`
`payment Jo-you of any sonexempt debt owedbythe Judgment Debtor(s). Make this demand upon the main office of any financialinstitution having
`its mairt-6ffice within your county.If the main
`office is not within your county, but a branch office of the institution is within
`county, make
`
`
`demand on an employee ofsuch branch office as long the empl andthebranch office have been designated by the financial institution in
`accordance with regulations adopted by the commissionerof banking. Only upon demand of a financialinstitution which does not have any main
`office or branch office in this state, demand may be madeby certified mail, return receipt requested.
`After having made demand you ere directed to serve a true and attested copyofthis execution, togetherwith the attached affidavitand Exemption
`Claim form, Financial Execution (form JD-CV-24A), with your doings endorsed thereon, upon thefinancial institution officer upon whom the demand
`was made. Receive the sum paid by the financial ins
`n and applyit on this execution in accordance with the provisions ofGeneral Statutes §
`Do not serve more than one financialinstitution execution per Judgment Debtorat a time, including copies.
`After service of an execution on onefinancialinstitution, do not serve the same execution or a copy on another
`financial institution until receiving confirmation from the precedingfinancialinstitution that the Judgment
`
`Debtorhadinsufficient funds available for collection to satisfy the execution. However, any additional service
`
`of an execution mustnot be made later than 45 days from yourinitial receipt of the execution.
`
`Aliso, after service of an execution, do not serve the same execution or a copy on the financialinstitution if an
`
`electronic direct deposit from a readily identifiable source described in General Statutes § §2-376b (c) was
`
`made to the Judgment Debtor's accountwithin the look-back period described in General Statutes § 52-376b
`
`
`(c) (2 months or, with regard to federal benefits, such greater period as required by federal law). If no such
`DSSQUENR
`
`deposit was made, you may $
`Hy,serve the same execution if the execution has not expired or
`
`
`otherwise become unenforceable
`,
`ot-and make d sdraj rn ofthis writwith your doingsthereon, according to law.
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` Page 1 of 2
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`163:/0
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`NOTE:The provisions of General Statutes § 52-367b, as amended, take precedence overtheseinstructions.
`
`Instructions to FinancialInstitution Upon Receipt of a Financial Institution Execution When Judgment
`Debtoris a Natural Person
`1. If any funds are removed from the Judgment Debtor's account pursuant to GeneralStatutes § 52-367b(c), complete
`sectionII of the attached Exemption Claim Form,FinancialInstitution Execution (form JD-CV-24A) and take the following
`actions:
`(1) Send 2 copies of both this form and the Exemption Claim Form, Financial Institution Execution form to the
`Judgment Debtor and any secured party that is a party to a control agreement between you and the secured party under
`article 9 oftitle 42a of the General Statutes. Copies must be sent postage pre-paid, to the last known addressin your
`recordsofthe recipient; and (2) Issue notice to the accountholder,orto a fiduciary who administers the account and
`receives communications on behalf of the account holder, in the time and mannerstated in Federal Regulations
`31 CFR 212.6 and 212.7.
`2. Remove from the Judgment Debtor's account the amountof any debts due from you to the Judgment Debtor not exceeding
`the total amountincludedin box 9 of the application on page 1 ofthis form, plus postjudgmentinterest, if ordered by the
`court, and the serving officer's fee. You musttake this action before your midnight deadline, as defined in General Statutes
`§ 42a-4-104.
`Leave in the Judgment Debtor's account (A)the full amountof electronic direct deposits that are readily identifiable as
`exemptfederal veterans’ benefits, Social Security benefits, including, but notlimited to, retirement, survivors’ and disability
`benefits, supplemental security income benefits, exempt benefits paid by the federal Railroad Retirement Board orthe
`federal Office of Personnel Management, unemployment compensation benefits exempt under General Statutes § 52-352b
`child support payments processed and received pursuant to Title IV-D of the Social Security Act, and (B) the amountof the
`electronic direct deposits, not to exceed $1,000, that are readily identifiable as wages provided such deposits were madeto
`the account during the look-back period of two months precedingthe date that the execution was served onthe financial
`institution, or, with regard to federal benefits, such greater time as required by federal law. If no such deposits have been
`madeto the Judgment Debtor's account during the look-backperiod,orif such readily identifiable funds are less than
`$1,000, leave in the account as exempt pursuant to General Statutes § 52-352b(18), the lesser of the account balance or
`$1,000 in the aggregate. To the extent that such fundsareleft in the account as exempt pursuant to General Statutes §
`52-352b(18), the provisions of that section shall not be the basis for a claim of exemption pursuantto this section in
`responseto a levy of execution. However, nothingin this paragraph shall be construedtolimit yourright or obligation to
`remove such funds from the Judgment Debtor's accountif required by any other provision of law or by a court order. The
`Judgment Debtorshall havefull and customary accessto any fundsleft in the account. You may notify the Judgment
`Creditor that funds have beenleft in the Judgment Debtor's accountpursuantto this provision. Also, nothingin this
`paragraph shall alter the exempt status of funds which are exempt from execution under General Statutes § 52-367b(a) or
`under any other provision of state or federallaw,or the right of a Judgment Debtorto claim such exemption. Further,
`nothing in this paragraph shall be construedto affect any otherrights or obligationsof the financialinstitution with regard to
`the funds in the Judgment Debtor's account.
`‘
`3. Hold the amount removed from the Judgment Debtor's account pursuantto this execution for 15 days from the date you
`mail the copies ofthis form and the Exemption Claim Form, FinancialInstitution Execution form to the Judgment Debtor
`and any secured party. During the 15 day period you mustnotpay theofficer serving this execution.
`if the Judgment Debtor returns the Exemption Claim Form, Financial Institution Execution form orother written notice that
`an exemptionis being claimed orif any secured party delivers to you written notice of their claim of a prior perfected
`security interest in the account, you must, within 2 business days of receipt of such notice, senda copy of such notice to
`the clerk of the court that issued the execution. Continue to hold the amount removed from the Judgment Debtor's account
`for 45 days or until you receive a court order regarding disposition of the funds, whicheveroccursfirst. If no orderis
`received within 45 days of the date you send a copyof the Exemption Claim Form, FinancialInstitution Execution form or
`notice of exemption or a secured party claim notice to the clerk of the court, return the funds to the Judgment Debtor's
`account.
`
`*
`
`5. If you do not receive the Exemption Claim Form, FinancialInstitution Execution form or securedparty claim notice within 15
`days of mailing the required documentsto the Judgment Debtor and any secured party, you must, upon demand,pay the
`serving officer the amount removed from the Judgment Debtor's account.
`6. If no Exemption Claim Form, FinancialInstitution Execution form or secured party claim noticeis filed orif 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 youfail or refuse to do so, you shall be liable in an action to the Judgement Creditor(s) namedin the
`execution for the amount of nonexempt monies which youfail or refuse to pay, excluding funds of up to $1,000 which you
`in good faith allowed the Judgment Debtorto access pursuant to General Statutes § 52-367b(c).
`7. If you pay exempt monies from the accountof the Judgment Debtorcontrary to theseinstructions, or the provisions of
`General Statutes § 52-367b, you shall beliable in an action to the Judgment Debtor for any exempt monies paid and you
`shall refund or waive any chargesof fees by you, including, but not limited to, dishonored check fees, overdraft or minimum
`balance service charges and legal process fees, which were assessed as a result of such payment of exempt monies.
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`JD-CV-24 Rev. 11-21
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`Page 2 of 2
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`For Information on ADA accommodations,
`contact a court clerk or go to: wwwjud.ct.gov/ADA,
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`
`EXEMPTION CLAIM FORM
`FINANCIAL INSTITUTION EXECUTION
`
`JD-CV-24A Rev. 10-21
`C.G.S. §§ 31-58(i), 52-321a, 52-350a, 52-352b, 52-36 1a,
`52-367b; 29 U.S.C. 206(a)(1)
`
`SEE INSTRUCTIONS ON BACK/PAGE 2
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`S
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`Name and address of Judgment Debtor or Attorney
`(To be completed byjudgmentcreditor or attorney)
`
`To:
`
`0
`Adrianna M.Davis
`466 Second Avenue
`West Haven, Connecticut 06516
`
`L
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`7
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`J
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`TATE
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`ECTICUT 4
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`SUPERIOR COURT :
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`cc
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`www,jud.ct.gov
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`1
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`MXMPEX
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`Section 1 - (To be completed byjudgmentcreditor)
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`Name and address of Court (Number, Street, Town and Zip Code)
`
`
`Housing
`Judicial
`LJ Session
`[x] District
`Ansonia-Milford Superior Court, 14 West River Street, Milford, Connecticut 06460
`
`
`
`
`Nameof case
`Docket number
`Nameof Judgment Debtor
`
`Adrianna M. Davis
`AAN-CV-22-6049395-S
`
`Connecticut Oral & Maxillofacial Surgery
`Centers, PC y. Davis, Adrianna M.
`
`Section 2 - (To be completed byfinancialinstitution - see instructions on back/page 2)
`Nameand addressoffinancialinstitution to which exemption claim (if any) is to be retumed
`
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`Date of mailing to Judgment Debtor
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`
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`Last 4 Digits of the Account Number(s)
`Amountand type of exempt funds not removed
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`Amount removed pursuantto execution
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`
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`|_| Additional sheet(s) attached hereto and made a part hereof (if necessary).
`
`
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`Section 3 - Notice to Judgment Debtor
`As a result of a judgmententered against you, the attached execution has been issued against funds deposited by you in the
`financial institution named above. To complywith this execution, the financialinstitution has removed the amount of money indicated
`above from the account(s)listed above.
`THE MONEYIN YOUR ACCOUNT(S) MAY BE EXEMPT FROM EXECUTION - The moneyin your account(s) may be protected from
`execution by state statutes or by otherlaws or regulations of Connecticut or of the United States. A checklist and a description of the most
`common exemptions established by law are setforth below.
`HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW.If you wish to claim that the money removed from your account(s) pursuant
`to this execution is exempt by law from execution, you mustfill out and sign before a properofficial the Affidavit of Claim of Exemption
`below and mail or deliver this exemption claim form to the financialinstitution at the above address. This form must bereceived by the
`financialinstitution no later than 15 days from the DATE OF MAILING TO THE JUDGMENT DEBTORindicated above.
`Uponreceipt of this form the financialinstitution will sendit to the Superior Court and the court clerk will notify you and the judgment
`creditor of the date on which a hearing will be held by the court to determine the issues raised by your claim.
`
`SECTION 4 - AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW
`I, the judgment debtor named above,claim and certify under the penalty of false statement that the moneyin the above accountis
`exempt by law from execution as follows:
`(selectall that apply to the funds containedin this account)
`[_] Social Security benefits (section 52-352b(7))
`[_] Private pension,trust, retirement, or medical savings account
`Cl Unemployment benefits (section 52-352b(7))
`payments (sections 52-321a, 52-352b(13))
`| Worker's Compensation benefits (section 52-352b(7))
`[_] Health ordisability insurance payments (section 52-352b(5))
`[_] Veteran's benefits (section 52-352b(7))
`i] Other claim of exempt funds (Explain basis for claim of exemption):
`[| Public Assistance payments (section 52-352b(4))
`[] Wages earnedby a public assistance recipient under an
`incentive earnings or similar program (section 52-352b(4))
`Cl Court-ordered child support payments (section 52-352b(8))
`[_] Alimony and support other than child support* (section 52-352b(14))
`*See Note Regarding Exemption for Alimony and Support on back/page 2.
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`Amountclaimed to be exempt
`if less than the entire amount:
`
`.
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`Signed
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`Complete mailing address of Judgment Debtor
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`Subscribed and sworn
`to before me on:
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`Date
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`eesigned
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`Telephonenumber
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`At (Town)
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`Signed (Notary Public, Commissioner of Superior Cour?)
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`Page 1 of 2
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`Instructions
`
`To Financial Institution
`1. Complete section 2 of this form and (1) send 2 copies
`of this form andthe financial institution execution form
`to the judgment debtor and to any secured party thatis
`party to a control agreement betweenthefinancial
`institution and such secured party underarticle 9 of
`title 42a pursuantto General Statutes § 52-367b and
`(2) mail notice to judgment debtor as required by
`SICFR212.6 and 212.7.
`2.If this claim of exemption is returned completed,fill out
`Section 6 of this form and mail, within two business
`days,to the issuingclerk's office at the address of
`court indicated on the front side. See additional
`instructions on the financialinstitution execution form.
`
`To Clerk
`1. Attach this form to eachfinancial institution execution issuedin a civil or
`family matter against a judgment debtorthatis a natura! person.
`2. Deliver the execution along with this form to the judgmentcreditor
`requesting the execution.
`3. Ifjudgment debtor completes andreturnsthis form claiming an exemption,
`enter the appearanceof the judgment debtor with addresssetforth on
`page 1.
`4. Set matter down for hearing.
`5. Complete Section 7 below.
`6. Sendfile-stamped copy ofthis form to judgment debtor and judgment
`creditor.
`
`7. After hearing, send copy of any order entered to the financialinstitution.
`
`Note Regarding Exemption for Alimony and Support
`Alimony and Support, other than child support, are exempt only to the following extent:
`The amountof alimony and support, other than child support, that may be subjectto levy or other withholding for paymentof ajudgmentis
`the lesser of (1) twenty-five percentof the individual's disposable earningsfor that week, or (2) the amount by which the individual's
`disposable earnings for that week exceedforty times the higherof (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair
`Labor Standards Actof 1938, U.S.C. Title 29, Section 206(a)(1), or (B), the state minimum hourly wage under subsection (i) of Section
`31-58, in effect at the time the earnings are payable.
`GeneralStatutes § 52-350a(4) defines "disposable earnings”as that part of the earnings ofan individual remaining after the deduction from
`those earnings of amounts required to be withheld for paymentof federal income and employmenttaxes, normal retirement contributions,
`union dues andinitiation fees, grouplife insurance premiums, health insurance premiums andfederaltax levies.
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`Section 5 - Proper Officer Must Complete this Section
`Nameandtitle of properofficer
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`Date of service onfinancialinstitution
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`Telephone number
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`Section 6 - (To be completedby financial institution upon return of exemption claim form)
`Dateclaim received
`Date mailed to court
`Nameoffinancialinstitution
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`Telephone number
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`Section 7 - Notice to JudgmentDebtor and Judgment Creditor
`The money removed from your account(s) pursuantto this execution is being held for (1) forty-five days from the date the
`exemption claim form wasreceivedby thefinancialinstitution designated on the front of this form or (2) until disposition ts
`ordered by the court at a hearing to be held at on the date set forth below, whichever occurs earlier.
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`Date of hearing Time of hearing|| am. Courtroom
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`|| p.m.
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`Signed (Assistant Clerk)
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`Order
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`Date signed
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`The Court/Magistrate, having held a hearing to determine the issues raised bythis claim, hereby orders that:
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`By the Court (Name of Judge/Family Support Magistrate/Magistrate)
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`[_] Judge
`Date signed
`Signed (Judge/Family Support Magistrate/Magistrate/Assistant Clerk)
`
`
`L_| Magistrate
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`[_] Fsm
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`accommodation in accordance with the ADA,contact a court clerk or an ADA contact personlisted at www.jud.ct.gov/ADA.
`
`ADA NOTICE
`The Judicial Branchof the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you heed a reasonable
`
`JD-CV-24A (page 2) Rev. 10-21
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`Page2 of 2
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