Fill and Sign the Occupancy Payments Form

Housing Session at:G.A. No. Judicial District of: I hereby certify that a copy of this motion was mailed/ delivered to all counsel and pro se parties of record on: JD-HM-27 Rev. 3-2000 C.G.S. § 47a-26b ADDRESS OF COURT DOCKET NO. MOTION FOR USE AND OCCUPANCY PAYMENTS $ The plaintiff(s)/landlord(s) ask(s) that the court order the defendant(s)/tenant(s) to deposit with the court payments for use and occupancy of the premises at the above address in an amount equal to the: (Complete box 1 or 2 below) 1. Last agreed upon rent. The last agreed upon rent was SIGNED (Plaintiff/Plaintiff's Attorney) NOTICE TO DEFENDANT(S)/TENANT(S) INSTRUCTIONS TO PLAINTIFF (LANDLORD) File the original with the clerk and mail a copy to the defendant. Retain a copy for your records. TELEPHONE NO. COMPLETE ADDRESS OF PREMISES (Including Apt. No., if any) NAME(S) OF PLAINTIFF(S)/LANDLORD(S) NAME(S) OF DEFENDANT(S)/TENANT(S) MOTION STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov payable monthly. weekly. 2. Fair rental value of the premises. (Use ONLY in absence of a last agreed upon rent.) DATE SIGNED DATE SIGNED (Plaintiff/Plaintiff's Attorney) NAME OF EACH PARTY SERVED* ADDRESS AT WHICH SERVICE WAS MADE *If necessary, attach additional sheet with names of each party served and the address at which service was made. You may file an objection to the plaintiff's motion with the clerk at the above address of court. If you do so within five (5) days of the date the above motion was filed, the court will conduct a hearing on the motion before entering an order for use and occupancy payments. You can find out the date the motion was filed by calling the clerk's office. If you do not file your objection within this five day period, the court will enter an order for use and occupancy payments without a hearing. You will be notified by mail. You may also file an objection at any time after the five day period has expired, but an order for use and occupancy payments will still enter. A hearing will then be held to determine if the order should remain in effect or be modified. If you file an objection during or after the five day period, you will be notified by mail of the hearing date and time. To claim an objection, state your reason(s) for doing so in the space provided below. Complete the certification section and make two copies. File the original with the clerk at the above address of court and mail a copy to the landlord or the landlord's attorney if he or she has one. Keep a copy for your records. OBJECTION TO USE AND OCCUPANCY PAYMENTS I object to the motion or order for use and occupancy payments for the following reasons: I hereby certify that a copy of this motion was mailed/ delivered to all counsel and pro se parties of record on: SIGNED (Defendant/Tenant, Attorney for Defendant/Tenant) *If necessary, attach additional sheet with names of each party served and the address at which service was made. SIGNED (Defendant/Tenant, Attorney for Defendant/Tenant) PRINT NAME SIGNED AT LEFT DATE SIGNED DATE NAME OF EACH PARTY SERVED* ADDRESS AT WHICH SERVICE WAS MADE