CERTIFICATE OF COMPLETION OF LIMITED APPEARANCE JD-CL-122 Rev. 2-16 P.B. 3-9(c) STATE OF CONNECTICUT (For Court Use Only) SUPERIOR COURT www.jud.ct.gov CERTCOM Instructions to Attorneys: 1. Fill out the form, including the certification section at the end of the form. File the original paper version of this form with the clerk. Mail or deliver a copy to all attorneys and self-represented parties of record. 2. Event(s) or Proceeding(s) for which this Certificate of Completion is being filed must exactly match the event(s) or proceeding(s) on the Limited Appearance form JD-CL-121. *CERTCOM* The Judicial 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 person listed at www.jud.ct.gov/ADA. Docket number ADA NOTICE Name of Case (Full name of Plaintiff v. Full name of Defendant) Address of Court (Number, state, town and zip code) - - -S Judicial District Small Claims Housing I have completed my representation for (Name of party/parties) for the following (Date filed) event(s) and/or proceeding(s) as defined on the Limited Appearance (form JD-CL-121) filed with the court on Name of Proceeding or Event Proceeding or Event Date Name of Proceeding or Event Family - Hearing on Order for Relief from Abuse Civil Protection Order Pretrial Conference Status Conference Civil - Discovery/Scheduling Order Conference Trial Management Conference Family - Special Masters Conference Pre-Judgment Motion(s) / Hearing(s) (Provide additional description, if necessary) Family - Conciliation Session Civil - Case Evaluation Conference Mediation Other ADR Process Session Foreclosure Mediation Program - Premediation Foreclosure Mediation Program - Mediation Trial Civil - Jury Selection Proceeding or Event Date Post-Judgment Motion(s) / Hearing(s) (Provide additional description, if necessary) Other (Specify): (Provide additional description, if necessary. Be as specific as possible, for example: entry number(s), file date(s), title(s) of motion(s).) Signed (Individual attorney) Name of person signing at left (Print or type) Juris number Date signed Certification I certify that a copy of this document was or will immediately be mailed or delivered electronically or non-electronically on (date) to all attorneys and self-represented parties of record and that written consent for electronic delivery was received from all attorneys and self-represented parties receiving electronic delivery. Name and address of each party and attorney that copy was mailed or delivered to* For Court Use Only *If necessary, attach additional sheet or sheets with name and address which the copy was mailed or delivered to. Signed (Signature of filer) Print or type name of person signing Date signed Telephone number u Mailing address (Number, street, town, state and zip code) American LegalNet, Inc. www.FormsWorkFlow.com