ON_/EFAXWESTHZ 1071072025 10:12:14 AM PAGE 17002 £88-294-5658
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`EXEMPTION CLAIM FORM
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`STATE OF CONNECTICUT 55
`FINANCIAL INSTITUTION EXECUTION |
`JO-CV-24A Rev. 10-21 ) SU PER!OR COURT |
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`C.6.5. §§ 31-58(), 52-321a, 52:350a, 52-362b, 52-361a, SEE INSTRUCTIONS ON aAcmPAGEuz" ' www.jud,ct.gov
`52-367b; 29 U.S.C. 206(a)(1) STAMEDRD-H LK
`Neme and address of Judgment Debtor or Atiomey JUDICTAL DISTRICT ,
`‘ {To be compfteted by judoment creditor or aflomey) - - P COURT USE ONLY
`. ) - o MXMPEX
`To: T mamkapvan . T8 05T 10 Al 33 -
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`236 Park Sirst | (AR
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`New Canaan, Connecticut 06840
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`L ' Jd
`Section 1 - (To be completed by Judgment creditor)
`Judicial Housing Name and addrass of Caud?l?umbsq Street, Towrn and 2{p Code)
`[X] pistrict L__] Sesslon 123 HOYT STREET, STAMFORD, CT 06905
`Name of casa Name of Judgment Debtor . Docket number
`ADVANI, MANIK v. PARK MEAD MANIK ARDVANI : FST-CV17-6032437-S
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`. CONDOMINIUM ASSOCIATION
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`Section 2 - (To be completed by financial institution - see Instructions on back/page 2)
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`Narme and address of financlal institution o which exemption claim (if any) Is to be relumed’ Date of malling to Judgment Dabtor »
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`o ¢ LY [ gtvett, New Canaan , CF 0684! 10/10 2025
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`Last 4 Digits of the Account Number(s Amaunt ramoved purfuant o execulion A‘mounk and type of exempt funds nof removed
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`266E 19,646. 6¥ 3%,54S. %3 '
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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
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`As a result of a judgment entered against you, the attached execution has béen issued against funds deposited by you in the
`financlal institution named above. To comply with thls execution, the financial Institution has removed the amount of money lndlcated
`above from the account(s) listed above,
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`THE MONEY IN YOUR ACCOUNT(S) MAY BE EXENMPT FROM EXECUTION - The money in your account(s) may be protected from
`execution by state statutes or by other laws or regulations of Conneclicut or of the United States..A checklist and a desocription of the- most
`common exemptions established by law are set forth below.
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`HOW TO CLAM AN EXEMPTION ESTABLISHED BY LAW. If you wishto c¢laim that the money removed from your account(s) pursuant
`to this execution is. exempt by law from executlon, you must fill aut and sign befare a proper officlal the Affidavit of Claim of Exemption
`below and Mmail or deliver thls exemption cfaim form to the finanelal 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.
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`Upon recelpt of this form the financlal institution will send Itto the Superior Caurt and the court clerk will nofify you and the judgment
`creditor of the date on whlch a hearing will be held by the court to determine the Issues raised by your claim.
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`SECTION4 - AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW
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`1, the judgment debtor named above, ¢lalm and certify under the penalty of false statement that the money in the above accou nt is
`exempt by law from execution as follows: (select all that apply to the funds confained in this account)
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`Sacial Securily beneflts (section 82-352b(7)) _ Private penslon, trust, retirement, or medical savings account
`{T] tinemployment benefits (section 52-352b(7)) ) payments (sections 52-321a, 52-352b(13)}
`[T Worker's Compensation benefits (section $2-8352b(7)) [[] Health or disability insurance. payments (sectlon 62-352b(§))
`[] Vveteran's beneflis (sectlan 52-3521(7)) [] Other claim of exempt funds (Explain basis for cfalm of exempian):
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`[T Public Assistance payments (section 52-352b(4))
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`] Wages eamed by a pubiic assistance reciplent under an
`incentive earnings or similar program (section §2-352b¢4)) .
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`7] Court-ordered child support payments {(section 52-352b(8)) . Amount claimed to be exempt.
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`[] Alimony and support other than child support* (section 52-352h(14)) If less than the entire amount:
`*Sea Note Regarding Exemption for Afimony and Sypport on back/page 2,
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`Signed - . " Date slgned
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`Compisie mailing addrags of Juégment Debtor .
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`Subsoribed and sworn Date — A (Town) p C
`to beforemeon: {0=-10-2% C(M(aalfl ¢ '(/
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`. Print Form’ Page T of 2
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`Instructions
`To Financial Institution To Clerk
`1. ,Cor_n.ple‘te section 2 of this form and (1) send 2 coples 1. Altach this form to each financial institution execution issued in a clvil or
`of this form and the financlal institution execution form family matter against a judgment debtor that is a natural person.
`to the judgment debtor and to any secured party thatis 2. Deliver the execution along with this form to the judgment creditor
`party to a control agreement between the financlal requesting the execution,
`iglsetlgjzt‘fn :g?j::tc gseeggr;g(psatra%z\sd grsa;‘zn?é‘;g : fd 3. if judgment debtor completes and returns this form-claiming an exemption,
`p i - n enter the appearance of the judgment debtor with address set forth on
`(2) mall notice to judgment debtor as required by ] age 1
`31CFR212.8 and 212.7. pags 1.
`] : 4. Set matter down for hearing.
`Section 8 of this form and mail, within two business " :
`days, to the Issuing clerk's office at the address of 6. f:::fl t:;i:'e-starnped copy of this form to judgment debtor and Judgment
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`courtindicated on the front side. See additional
`instructions on the financisl institution execution form.
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`7. After hearing, send copy of any order entered to the financial insfitution.
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`Note Regarding Exemption for Alimony and Support -
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`Alimony and Support, other than child support, are exempt only to the following extent:
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`The amount of alimony and support, Gther than child support, that may be subject to levy or ather withholding for payment of a judgment is
`the lesser of (1) tweniy-flve percent of the individual's disposable eamings for that week, or (2) the amount by which the Individual's
`disposabile earnings for that week exceed forty times the-higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair
`Labor Standards Act of 1938, U.S.C. Title 28, Section 206(a)(1}, or (B), the state minimum hourly wage under subssction (i) of Section
`31-58, In effect at the time the eamnings are payable.
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`General Statules § 52-350a(4) defines "disposable earmnings” as that part of (he eemings of an Individual remaining after the deduction from
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`those earnings of amounts required to be withheld for payment of federal Income and employment taxes, normal relirement contribufions,
`union dues and-initiation fees, group life Insurance premiums, heaith insurance premiums and federal tax levies. '
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`Section 5 - Proper Officer Must Complete this Section
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`Narmig and fitle of proper officer Dale of service'on financia! instilution Telephone number
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`Section 6 - (To be‘completed by financial institution upon return of exemption claim form)
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`“Date claim recaved Date malled to court Name of financtal institufion Telaphone number
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`Section 7 - Notice to Judgment Debtor and Judgment Creditor
`The monsy removed from your account(s) pursuant to this execution is being held for (1) forty-five days from the date the
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`tion claim form was received by the financial institution designated on the front of this form or (2) until disposition Is
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`exemp!
`orderad by the court at a hearing to be held at on the date sat forth below, whichever occurs: earlier.
`Date of heatlng Time of hearing a.rm. Courtroom
`i ] p.m.
`Signed {Assisfant Clerk) Date sigred
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`Order ' .
`The Court/Magistrate, having held a hearing to determine the issues raised by this clalm, hereby orders that:
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`By the Court” {Nerme of Judge/Family Support Magisirate/Magisirate)
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`[1dudge [7] Fom [] Magistrate
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`Signed {Judge/Family Support Magistrate/tagistrate/Assistant Clark) ' Dale signed
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`' The Judiclal Branch of the State of Connecticut complies with the Americans with Disablilties Act (ADA). If you need a reasanable
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`ADA NOTIGE
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`accommodation In accortdance with the ADA, contact a court clerk or an- ADA contact person Ilste'd “at www,jud.cl.gowADA.
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`JD-CV-24A (pags 2) Rev. 1021 PNt Form Page 20f 2 " [ Resa&tForm
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