Fill and Sign the Exemption Claim Form Connecticut Judicial Branch Ctgov

CONNECTICUT JUDICIAL BRANCH SUPERIOR COURT www.jud.ct.gov Pursuant to the attached order of the court (form JD-CV-73) , the above-named judgment creditor submits this application for a hearing on the exempt status of the funds identified above that were left in the judgment debtor's account pursuant to subsection (c) of C.G.S. § 52-367b, as amended by section 1 of Public Act 01-196. APPLICATION FOR HEARING ON EXEMPT STATUS OF FUNDS JD-CV-72 New 2-02 C.G.S §52-367b, P.A. 01-196 INSTRUCTIONS Attach a copy of form JD-CV-73, "Affidavit Re: Exempt Funds" authorizing this application. Complete the following application and present to the clerk of the court where the action is pending. DOCKET NO. NAME OF CASE (FIRST-NAMED PLAINTIFF V. FIRST-NAMED DEFENDANT) APPLICATION FOR HEARING ON EXEMPT STATUS OF FUNDS Judicial District at: APPEXE COURT USE ONLY I hereby certify that a copy was mailed/delivered to all counsel and pro se parties of record on: SIGNED (Individual attorney or pro se party) X * If necessary, attach additional sheet with names of each party served and the address at which service was made. DATE PHONE NO. (area code first) ADDRESS AT WHICH SERVICE WAS MADE* NAME OF EACH PARTY SERVED * CERTIFICATE OF SERVICE The court having heard the above application finds: Judge/Magistrate FOR COURT USE ONLY SIGNED (Individual attorney or pro se party) X NAME OF JUDGMENT CREDITOR NAME OF JUDGMENT DEBTOR AMOUNT OF FUNDS CLAIMED AS NOT EXEMPT TYPE OF FUNDS Small Claims Area at: Housing Session at: G.A. at: DATE COURT ORDER (For Court Use Only) Date