0: Hartford J.D.
`
`Page: 6 of 7
`
`2024-12-05 16:18:49 GMT
`
`18606477950
`
`Fram: Diana, Conti & Tunila, LLF
`
`FORECLOSURE MEDIATION
`CERTIFICATE
`JD-CV-108 Rev, 10-24
`C.G.S. §§ 49-31k, 49-34/, 52-380a; PA, 15-124
`
`For information on ADA
`accommodations, contact the
`Centralized ADA Office at 860-706-5310
`or go to: www.Jud.ct.gov/ADA/
`
`STATE OF CONNECTICUT 4
`SUPERIOR COURT ASS
`JUDICIAL BRANCH 4
`wwwJud.ct.gov
`
`<a
`if the plaintiffis not represented by an attorney, and to all parties who havefiled an appearance in the case.
`
`Instructions to applicant
`1. Use this form if the retum date in your case is on or after July 1, 2009.
`2. Fill out this Certificate form and an Appearance form, JD-CL-12 and
`file them with the court not more than 15 days after the return date on the Summons.
`3. You must mail or deliver a copy of this completed Certificate form to the plaintiff's attomey, or to the plaintiff
`
`This form will be used to determine youreligibility for the Foreclosure Mediation Program.
`
`Name of case (Plaintiffon Summons v. Defendant on Summons) Docket number (To be filledinbycourt staf)
`
`CITIBANK,N.A., NOTIN ITS INDIVIDUAL CAPACITY BUT v. MANN, HILARYLEt Al HHD-CV24-6193675-S
`
`Retum date (On upparright portian of Summons)|Judicial District of (On upperleft partion of Summons,
`11/26/2024
`Hartford
`Your name
`
`Emily Luna, Esq. on behalf of the Defendant Liane Mann
`Address
`, straol, town, state,
`
`Diana, Cont! & Tunila, LLP, 1091 Main St, Manchester, CT 06040
`Telephone number
`Business phone
`860-643-2181; Ext. 35
`
`Call phone
`
`A.
`
`If you are an individual, answer the following questions:
`[_]No
`[x] Yes
`1. Do you own the property?
`
`2. Do you live in the property? [x] Yes[]No
`3.
`Is it your primary residence?
`[x] Yes
`[]No
`4.
`Isita1, 2,3 or 4 family residential property located in Connecticut? [x] Yes
`[_] No
`5.
`{s this a mortgage foreclosure?
`[3] Yes
`No
`5a. Are you a borroweron the note?
`[_] Yes
`No
`6. Are you a debtor In a consumerjudgmentlien?
`[] Yes
`[x] No
`Ifyou are not a borrower on the note, but answered "Yes" to questions (1) through (5) and you are the spouse or former
`spouse of a borrower, go to Section C.
`
`Ifyou answered “yes” to questions (1) through (5a) and another defendantin this case has requested or may requestin
`Section C to participate in the Foreclosure Mediation Program as a Permitted Successor-in-interest, who became the
`ownerof the property as a result of divorce, legal separation, or a property settlement agreementrelated to a divorce or
`legal separation, go to Section D.1.
`
`OR
`
`B.
`
`If you arefiling this on behalf of a religious organization, answer the following questions:
`1. Doesa religious organization own the property?
`Cl Yes
`[]No
`2. Is the property located in Connecticut?
`[|] Yes
`[J] No
`3. Is the religious organization the borrower on the note?
`[]Yes
`[] No
`4. |s the return date in the case on or after October 1, 2011?
`[|] Yes
`[| No
`
`C. Permitted Successors-in-interest
`If you are not a borrower on the note, but answered “Yes” to questions (1) through (5) in Section A and you are
`the spouse or former spouse of a borrower, you may be able to participate in the Foreclosure Mediation Program
`as a Permitted Successor-in-Interest.
`Answerthe following questions to help the Court determineif you qualify:
`(-] No
`1. Are you a defendantin this case?
`{] Yes
` [_] No
`2. Is the return date in this case on or after October 1, 20157
`[a] Yes
`3. If you answered “yes” to (1) and (2), how did you become the owner of the property?
`(Select the box that applies to you, if any)
`[x] 3a. | became the only ownerof the property whenit was transferred to me from my deceased spouse's estate.
`(_] 3b. | becamethe only ownerof the property because my deceased spouse and| held jointtitle to the property.
`(L] 3c. 1 became the ownerof the property becauseit was transferred to me as a result of a divorce, legal separation, or
`a property settlement agreementrelated to a divorce or legal separation.
`if you selected 3c., go to Section D.2. and Section D.3.
`
`Page 1 of 2
`
`\
`
`

`

`o: Hartford J.D.
`
`Page:7 of 7
`
`2024-12-05 16:18:49 GMT
`
`18606477950
`
`/
`
`From: Diana, Conti & Tunila, LLF
`
`»
`
`D. Consents
`
`Ifa PermittedSuccessor-in-interest, who became the ownerofthe propertyas a result of divorce,legal
`-separation,ora:‘property:settlement agreement related toa divorce or. legal:separation, hasapplied or mayapply
`for the ForeclosureMediationProgram, you must complete this sectionto qualifyfor the ForeclosureMediation
`Program:(Select only thebox(es) that apply)
`wreyou:answered “Yes" to questions (1) through(5a) in Section A and anotherdefendanthas Tequested.ormay fequest
`toparticipate'in the Foreclosure Mediation Program as a Permitted Successor-in-Interest, who becametheowner of
`thepropertyas‘a result of divorce, legal separation, or a property settlement agreernent related toa‘divorceorlegal
`separation, select this box to complete your consent:
`[-] | consentto theplaintiff mortgagee’s disclosure ofmy non-public personal financial information’to the spouseor
`former spouse whoqualifies as a Permitted Sucéessor-in-interest to the extent that the plaintiffmortgagee has that
`information.
`
`2.
`
`3.
`
`If you answered “Yes” to questions (1) and (2) in Section C, and selected box3c., sélect this box to ‘completeyour
`consent:
`(_] | consentto the plaintiff mortgagee's disclosure of my non-public personalfinancial informationto all borrowers on
`this note, to the extent that the plaintiff mortgagee has that information.
`
`If youanswered “Yes”to questions (1) and (2) in Section C, and selected box3c., select this box to certify that-all
`borrowers on the note have provided their consent:
`(C1)
`| certify that all borrowers on the note have agreed to allow the plaintiff mortgageeto disclose’their non-public
`personalfinancial information to me, to the extent that the plaintiff mortgagee has that information,and that the
`borrowershaveshown their consent by (Select any box that applies):
`["] Submitting a Foreclosure Mediation Certificate containing their consent, or
`(_] Giving documentation to-the plaintiff mortgagee that allowsfor the full disclosureof the borrower"$ non-public
`personalfinancial information to me.
`
`
`
`Print name of person signing
`Emily Luna, Esq.
`
`—~ Date signed
`/Z
`
`A
`
`Certification
`| certify that a copyof this document wasorwill immediately be mailed ordelivered electronicallyor non-electronically on
`(date)_1z.{SfLOL
`fo all attorneys and self-represented: parties of record andthat writtenconsentfor electronic delivery was
`received fromall attorneysand self-répresented patties of record whoreceived orwill immediately be receiving electronic deliver
`
`
`Nameand address of each party and attomey that copy wasor will be mailed or delivered to°
`GFELLER LAURIE LLP
`LEOPOLD & ASSOCIATES PLLC
`977 FARMINGTON AVENUE
`80 BUSINESS PARK DRIVE
`SUITE110.
`SUITE200
`‘WEST HARTFORD, CT 06107
`ARMONK, NY 10504
`
`
`"If necessary, attach additional sheet or sheets with name and address which the copy wasor will be mailed or delivered to.
`Date signed
`Print or typo nameof person signing
`
`
`12/5] 2024
`
`
`| Emily Luna, Esq.
`
`
`Telephone number
`umber, street, town, state and2ip code)
`
`
`860-643-2181
`Diana, Conti & Tunila, LLP, 1091 Main St, Manchester, CT 06040
`
`Page 2 of 2
`
`