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`FINANCIAL INSTITUTIONEXECUTION
`PROCEEDINGS- JUDGMENT DEBTOR
`WHO {8S A NATURAL PERSON,
`orASEXESmen
`
`C.G.S. §§ §2-358b, 52-967b
`PA. 14-7, 14-9
`
`p06 26784766
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`STATE OF CONNECTICUT
`SUPERIOR COURT
`.
`7
`www.jud.cl.gov
`(Seepage 2 forinstructions to financialinstitution
`
`EN Hy
`a FEA BA"
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`AAT | I Iii)
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`EPAUSISIUIE
`
`and ADA Notice)
`an
`Instructions - Clerk
`Instructions - Judgment Creditor Or Attorney
`1. Check the file io ensure that the information provided
`1. Type orprint legibly
`:
`on the application is correct.
`2. Complete the application section;prepare original and2 copies.
`:
`2, Sign orginal execution.
`.
`3. Complete section 1 of the Exemption Claim Form, JO-CV-2da andattach to this form.
`3. Retum originalto.applicant. retain a copy forfile. H UH y
`4. Present ofiginalanc
`-eopy
`to clerkofcourt.Retdin a.copy...
`/
`
`
`| Addressafcourt” | ETE, 95 Washi Avni. ingen our Geographic|Docket number
`Hauttord SucicralSayreec ainy (Asme [ine] CV-27-6080948-8
`
`
`
`Name and mailing address‘of Judgment
`€ Teditoror Atiomney [To be completedby Judgment Creditor
`~
`|
`
`
`Sclomon'jand Solomon, P.C.
`1 Columbia Circle
`Albany, ‘NY
`12203
`
`; Name(s) and address(es) of Judgment Creditors)
`HARTFORD ACCLDENT AND INDEMNITY
`TUCSON |
`5447 BE STH ST
`5
`Namets) and address(es) ofdtidgment Debtors) rs
`S
`JARVIS GOMEZ -
`06106
`CT
`8 |
`71 HILLSIDE AVE APT 2 _ HARTFORD:
`
`
`
`
`& | Date ofjudgment (Inchicle, whereapplicable,|2. Ambunt of cosis. Amount ofjudgment ~~ 3. AmountofJudgment castsandTess (Add Tand2
`
`
`|
`= $7097.00
`——_prpldamentinterestand
`<
`{10/31/18
`$427.60 -
`_ $7524.60
`4,Totel amount paid (any "|S.Totalamount unpald’ (Subtract4 from 3)"|6. Application TeeTorTmancbt mantle ‘execition (ifnat walvedbythécoun”
`
`
`$0.00
`$7524.60
`;
`$205.00
`"
`7. Application: lees paidfor prior executions on thisjudgment
`
`
`5 BTotal of denis“T §. Other court orderedpostjudgment costs and fees 5, 6, 7 and é
`
`
`
`$0.00
`$7629.60
`
`
`
`
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`(“I Xo
`["} Yes
` of
`
` ck ffapplicable 1;
`
`
`
`
`
`
`
`postjudgmentInteres! wasordered by the court
`
`
`
`
`\€ this is4judgment i
`arising out of services tendered at a hospital, has a stay ofa financialinstitution execution been
`entered ffursuan! tojan installment payment order?
`{
`
`ffafinancy,| institutionexecution twasbey mentergd, hasre nent Debtordy i|.=ingtallmgntPaymentorder?
`Ifa stay
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`erePeerfoeener
`‘Datesinned
`Télephon@number
`
`
`
`
`518 456-7206
`
`Financial
`Hitution Execution
`To any prep Laificer,
`i
`Whereas on said Date of Judgment the above-named Judgment Creditor(s) recdvered judgment against the above-named Judgment Debtor(s) before the above-
`named court for the amountofjudgment, costs and fees stated above, as appears of recard, whereof execution remains to be done.
`These are, therefore, by autharity’of the state of Connecticut to command you:
`Within seven days fram yourreceipt of this execution, make demand Upon the main office of any financialinstitution having its main office within your county, or Ifsuch
`main office is not within your county and suchfinancialinstitution has one or more branch offices within your county, upon an employse of such a branch office, such
`employee and such branchoffice Having been designated, by the financlalinstitution in accordance with ragulations adopted by the commissioner of banking,for
`payment to you pursuant to section'52-367b(b) ofthe General Statutes of any nonexerptdebt due said Judgment Debtor(s), which sum shall not exceed the tolat
`unpaid judgment, costs and fees ag Stated above,plus postjudgment interest 2s ordered by the court,if applicable, plus the application fee and other court ordered
`postiudgment costs and fees and your ownfee. After having made such demand you ave directed to sarve a true and attested copy ofthis execution, together with the
`attachedaffidavit and exemption claim form, with your doings endorsed thereon, with the financialinstitution officer upon whom Such demand was made, Said sum
`shall bo received by you and applicd on this execution in accordance with the Provisions of section 52-367b of the General Statutes. You shall not serve more than ona
`financialinstitution execution perjudgment debtor at a time, including copies thereof. After service of an execution on one
`ForCourt Use Only
`
`
`
`financial institution, you shall not serve the same execution ore copy thereof upon anotherfinancialinstitution until receiving
`
`
`confirmation from the preceding financialinstitution that the judgment debtor hadinsufficient funds at the Praceding financial
`
`institution available for collection to ‘satisfy the execution, provided any such additional service is madenotlater than forty-five
`
`days from the receipt by you of such execution. After service of an execution, you shall not serve the same execution ora
`
`copy thereof upon suchfinancialingtitution if an electronic direct deposit from a readily identifiable source described in
`section 52 -376b (c) of the GeneralStatutes was madeto the judgment debtor's accountwithin the look-back period
`
`
`
`described in section 52 -378b(c) ofthe GengratStajues (sixty days or, with regard to federal benefits, such greater period as
`
`
`
`
`required by federal law). {f no such Yepesit was
`mg Je, you may subsequently serve the same execution ora copy thereof
`
`upon such institution, provided the SXecution hax’not expired or otherwise become unenforceable.
`Hereoffail
`f
`;
`Signed
`(Asg€tant
`e
`
`
`
`
`AZ
`—
`
`85711
`
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` Page 1 of 2
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`ANCIAL INSTITUTION EXECUTION PROCEEDINGS
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`'
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`NOTE: The provisions of section 52-367b, as amendedfrom time to time, take precedence over theseinstructions.
`
`instructions To Financial Institution Upon Receipt Of A Financial Institution Execution
`When JudgmentDebtorIs A Natural Person
`
`1.
`
`oy
`
`.
`
`If any funds are removed from the judgment debtor's account pursuant to subsection (c) of section 52-367b of the General Statutes,
`complete section |! of th8 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 secured party that is a party to a control agreement between you and such
`secured party underarticle 9 oftitte 42a of the General Statutes, postage pre-paid, at the last known addressofthe judgment debtor and
`of any such secured party with respect to the affected accounts on the records of your institution and (2) mail notice to the judgment
`debtor as required by 31GFR212.6 and 212.7.
`Remove from the judgment debtors account the amaunt of any debts due from you to the judgment debtor not exceeding the Total
`Amount Unpaid as appears on page 1 ofthis form plus interest and the Application Fee for Financial Institution Execution and other court
`ordered postjudgment casts or fees and the serving officers fee, before your midnight deadiine, as defined in section 42a-4-104 ot the
`General Statutes.
`{f an electronic direct deposit is readily identifiable as exempt federal veterans’ benefits, Social Security benefits,
`including, butnotlimited to, retirement, survivors’ and disability benefits, supplemental security income benefits, exempt benefits paid by
`the federal Railroad Retirement Board or the federal Office of Personnel Management, unemployment compensation benefits exempt
`under section 52-352b of the Connecticut General Statutes, or child support payments processed and received pursuantto Title IV-D of
`the Social Security Act were made to the judgment debtor's account during the look-back period ofeither the sixty-day period preceding
`the date that the executicn was served on you, or, with regard to federal benefits, such greater period as required by federal law then you
`shall leave the lesser of the account balance or one thousand dollars in the judgment debtor's account, provided nothing in this
`subsection shall be construed to limit your right or obligation to remove such funds from the judgment debtor's accountif required by any
`other provision of law oriby a court order, The judgment debtor shall have full and customary access to such fundsleft in the judgment
`debtor's account. You may notify ihe judgment creditor that funds have been Jeft in the judgment debtor's account pursuant to this
`provision. Nothing herein.shail alter the exemptstatus 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 debtor's account.
`You must hold the amount removed from the judgment debtor's account pursuant to this execution forfifteen days from the date you mail
`the copies of this form and the Exemption Claim Form to the judgment debtor and any securedparty. During suchfiftéen day period you
`must not pay the officer serving this execution.
`elf the judgment debtorretlims 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 in such deposit account, you must,
`within two business daysof 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 accountfor forty-five days or until a court order is received
`regarding disposition ofthe funds, whichever occursearlier. 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 judgment debtor's acdbunt.
`_ If you do not receive a claim of exemption or secured party claim 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.
`If no exemption claim or secured party claim notice is 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 you fail or refuse to do so, you shalt be liable in an
`action therefor to the judgement creditors) namedin the execution for the amount of nonexempt monies which youfail or refuse to pay
`over.
`If no exernption claim is filed or if the court orders you to pay the serving officer an amount removed from the judgment debtors
`account not exceeding the amount due on the execution and youfall or refuse to do so, you shall be liable in an action therefor to the
`Judgment creditor(s) name in the execution far the amount of nanexempt monies which youfai] or refuse io pay over, excluding funds of
`up to one thousand dollars which you in goodfaith allowed the judgment debtor to access pursttant ta subsection (c) of section 52-367b
`of the General Statutes.
`Jf 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%shal] 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 paid and you shall refund or waive
`any charges of fees by you, including, but notlimited to, dishonored check fees, overdratt fees or minimum balance service charges and
`legal process fees, which Were assessed as a result of such payment of exempt monies.
`
` ADA NOTICE
`
`
`The Judicial Branchof the State of Connecticut complies with the Americans with
`Disabilities Act (ADA). If you nead a reasonable accommodation in accordance with the
`
`
`ADA,contact a court clerk or an ADA conlaetpassonlisted al www.jud.cf.gowADA,
`
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`Page 2 of 2
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`GOC002 26784766 01 20190530133109 POG AS400 FFOO 002681343 OOS2N
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`JD-CV-24 (back/page 2) Rev.245
`he
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`PRTFRM # RMESKO .
`FRIPOG
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`ne nlnpmit
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`4
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`

`

`EXEMPTION CLAIM FORM
`FINANCIALINSTITUTION EXECUTION
`JD-CV-24A Rev.i-17
`C.G.S. 31-58(), 52-321a, 52-350a, §2-352b, 52-3612,
`52-3670, 29 U.S.C. 206(a}¢1)
`
`SEE INSTRUCTIONS ON BACK/PAGE 2
`
`To:
`
`rT
`
`Name and address of Judgment Debtor or Attomey
`(To be completed byJudgment creditor or attomey)
`b
`JARVIS GOMEZ
`71 HILLSIDE AVE APT 2
`HARTFORD
`
`06106
`
`cr
`
`7
`
`P97 26784766
`
`STATESUPERGReolRe
`www.jud.ct.gov
`
`
`Cina
`
`
`
`
`MXMPEX
`
`J
`
`
`
`L
`Section 1 —(To be completed byjudgment creditor)
`
`
`
`
`-Geographica
`‘Nameand eeeCourt(Number, Street,5andip Gore),
`‘Sudicial
`Housing »
`
`Area
`Pt
`LE
`ot
`*
`:
`K_] District
`[J Session iC) Number
`Ash
`
`re
`
`“NameatJudgment Debio”
`“Name of case
`°
`‘Rocket number
`
`
`
`
`JARVIS GOMEZ
`HARTFORD ACCIDENT AND INDEMNITY
`CV-17-6080948-S
`
`
`v.
`JARVIS GOMEZ
`f
`
`
`
`_Section 2 — (To be completed by financial institution - see instructions onback/page2)
`Name and address offinancialinstitution to which exemption claim (iany) is to be returned
`
`Date of mailing to Judgment Debtor
`
`‘Amount and type of readily identifiabla exemplfunds not removed
`
`
`
`
`Amount removed pursuant fo executian
`
`
`* Last 4 Digits afthe Account Number(s)
`7 | Additional sheet(s) attachedheretoand made a part hereof (/fnecessary).
`Section 3 — Notice To: Judgment Debtor
`As a result of a judgmend entered against you, the attached execution has been issued against funds deposited by you in the
`financial institution named ‘above. To comply with this execution, the financial institution has removed the amountof money indicated
`above from the accaunt(s) listed above.
`THE MONEYIN YOUR AGCOUNT(S) MAY BE EXEMPT FROM EXECUTION - The money in your account(s) may be protected from
`execution by state statutes or by other laws or regulations of Connecticut or of the United States. A checklist and a description of the mest
`common exemptions established by law are set forth below.
`HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW,If you wish to claim that the money in your account(s) is exempt by faw
`from execution, you mustfill gut and sign before a properofficial the Affidavit of Claim of Exemption below and mail or deliverthis
`exemption claim form to the tinancial institution at the above address. This form must be received by thefinancialinstitution no jater than
`15 days from the DATE OF MAILING TO THE JUDGMENTDEBTORindicated 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 the date on which 4 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 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”ail that appfy to the funds containedin this account)
`5
`Oo Social Security benefits:(seclion 52-352b(q})
`OC Private pension,trust, retirement, or medical savings
`[_] Unemptoyment benefite (section 52-352b(g))
`account payments (sections 52-321a, 52-352b(m))
`[_] Worker's Compensation benefits (section 52-352b(g))
`[_] Health ordisability insurance payments (section 52-352b(e))
`[_] Veteran's benefits (section 52-352b(g))
`C] An amountin the bank not to exceed $1000 (section 52-352b(r))
`EC] Public Assistance payrients (section 52-352b(d))
`T Other claim of exempt funds (Explain basts for claim ofexemption):
`
`im Wages earned bya public assistance recipient under an
`incentive earnings or sifnilar program (section 52-352b(d))
`| Cour-ordered child support payments (section 52-352b(h))
`{_] Alimony and support other than child support* (section 52-352b(n))
`*See Note Regarding Exemption for Alimony and Support on back/page 2.
`
`Amount claimed to be exempt
`if less thanthe entire amount:
`
`Signed
`
`4
`
`Complete mailing address of Judgment Debtor
`
`
`
`
`Dale Signed
`
`Telephone number
`
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`

`a
`Instructions
`To FinancialInstitution
`4. Complete section 2 of this form and (1) send 2copies
`of this form and the financial institution execution form
`to the judgment debtor and to any securéd party thatis
`party to a control agreement between thefinancial
`institution and such secured party underarticle 9 of
`title 42a pursuant to section 52-367b of the General
`Statutes and (2) mail notice to judgment debtor as
`reguired by 31CFR212.6'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 issuing clerk’s office at the address of
`court indicated on the front side. See addigonal
`instructions on the financial institution execution form.
`
`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 thejudgment debtor with address
`set forth an page 1.
`.
`4. Set matter down for short calendar hearing.
`5. Complete section 7 below.
`6. Send fite-stamped copyof this form to judgment debtor and judgment
`creditor.
`7. After hearing, send copy of any order entered fo the financial institution.
`
`Note Regarding Exemption for Alimony and Support
`Alimony and Support, othér than child support, are exempt only ta the following extent:
`The amountof allmony and Support, otherthan child support, that may be subject to levy or other withholding for payment of ajudgment is
`the lesser of (1) twenty-five percent ofthe individual's disposable earnings for that week, or (2) the amount by which the individual's
`disposable earningsfor thatweek exceedforty mes the higher of (A) the federal minimum hourly wage under Section 6(a){1) ofthe Fair
`Labor Standards Act of 7938 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 payabie.
`Section 52-350a(4) of the Connecticut General Statutes defines ‘disposable earnings"as thal part of the eamings of an individual remaining
`afier the deduction from those earnings of amounts required to be withheld for paymentoffederal income and employment taxes, normal
`retirement contributions, union dues andinitiation fees, grouplife insurance premiums, health insurance premiums and federal tax levies.
`
`1
`
`’ Date claim vocewed
`
`
`Section 5 — Proper Officer MustComplete This Section
`
`Name andlitle of properofficer
`Date of service on financial institution : Telephone number
`
`
`
`Section 6 — (To be compieted byfinancialinstitution upon returnofexemptionclaim|form) Talephone humber
` Datednailed'io court
`—
` Name offinancial instiulion
`
`
`&
`
`“Section 7 — Notice T¢ Judgment Debtor And JudgmentCreditor
`The assets in dispute are being held for (1) forty-five days from the date the exemption claim form was received bythe 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 foith below, whichever occursearlier,
`j Date of hearing
`Time of hearing
`.
` | am.
`
`{_| p.m.
`
`
`
`
`
`
`
`Signed (Assistant Clerk}
`
`Date signed
`
`Order
`The Court/Magistrate, havingheld a hearing to determine the issues raised bythis claim, hereby ordersthat:
`4
`
`By the Count (Narne of JudgerFanilly Support Megisirate/Magistrate)
`
`Signed (Judge/FamilySupportMagistrale/Magisirate/AssistantClerk}
`
`:
`
`
`
`[_] vudge
`| Datesigned
`.
`.
`
`[_] FSM
`
`[|] Magistrate
`
`.
`
`x
`
`~
`
`,
`ADA NOTICE
`The Judicia] Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable
`
`accommodation in accordance with the ADA, contact a court clerk or an ADA contact personlisted at ww.jud.ctgoviADA.
`
`SD-CV-248 (page 2) Rev. 1-47
`FRTIPO?
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`

`OFFICER’S RETURN
`
`STATE OF CONNECTICUT
`
`ss: NEW HAVEN
`
`COUNTY OF NEW HAVEN
`
`November 26, 2019
`
`by virtue hereof,
`there
`and
`Then
`Financial Execution Wholly Unsatisfied.
`
`I
`
`return this
`
`The within and foregoing is the original Financial
`Execution ‘with my doings hereon endorsed.
`
`ATTEST:
`
` ROBERT S. MILLER
`
`STATE MARSHAL
`
`NEW HAVEN COUNTY
`
`