CLAIM OF EXEMPTION CLIENT SECURITY FUND FEE JD-GC-22 Rev. 4-14 P.B. § 2-55, 2-55A, 2-70 C.G.S. § 51-81d EXEMPTIONS FROM THE CLIENT SECURITY FUND FEE A. FULL EXEMPTION - You are exempt from paying the client security fund fee if you meet any of the following requirements: 1. You have served or expect to serve on active duty in the armed forces of the United States for a period of more than six months during the calendar year for which the fee is due. If you serve on active duty for a shorter period of time during the calendar year, you are obligated to advise the office of the Client Security Fund Committee and pay the client security fund fee due for the year. Such payment shall be made no later than thirty days after the end of the calendar year, by sending a check in the amount of $75.00 payable to the Client Security Fund, to the office of the Client Security Fund, P.O. Box 1379, Hartford, CT 06143-1379. Your failure to do so may subject you to disciplinary action by the Superior Court. 2. You have retired from the practice of law in Connecticut by providing the required written notice of retirement to the Statewide Bar Counsel pursuant to Practice Book Section 2-55 or 2-55A. 3.You have resigned from the Bar of the State of Connecticut pursuant to the procedure set forth in Practice Book Section 2-52. 4. You have been disbarred. B. PARTIAL EXEMPTION - You are entitled to a 50% exemption if you meet the following requirements: You do not engage in the practice of law as an occupation* AND you have not and do not expect to earn more than $450 in legal fees or other compensation for services involving the practice of law during the calendar year for which the fee is due. If, after claiming a partial exemption, you engage in the practice of law as an occupation during the remainder of the calendar year, or you do not engage in the practice of law as an occupation but earn more than $450 in legal fees or other compensation for services involving the practice of law during the calendar year for which the fee is due, you are obligated to advise the office of the Client Security Fund Committee and pay the remaining client security fund fee due for the year. Such payment shall be made no later than thirty days after the end of the calendar year, by sending a check in the amount of $37.50 payable to the Client Security Fund, to the office of the Client Security Fund, P.O. Box 1379, Hartford, CT 06143-1379. Your failure to do so may subject you to disciplinary action by the Superior Court. *If being an attorney is a factor in an individual's employment, such attorney is deemed engaged in the practice of law as an occupation for purposes of this exemption and does NOT qualify for the partial exemption. For example, attorneys who are employed in positions such as state's attorney, assistant attorney general, or public defender, do not qualify for the partial exemption because being an attorney is a factor in their employment. The partial exemption is also not applicable to judges, judge trial referees, state referees, family support magistrates, family support referees and workers compensation commissioners. An attorney engaged in the practice of law as an occupation outside of Connecticut may NOT claim the exemption. INSTRUCTIONS FOR CLAIMING AN EXEMPTION To claim an exemption you must complete the below form and send it to the Client Security Fund, P.O. Box 1379, Hartford CT 06143-1379. If you are claiming a FULL exemption, do not send payment. If you are claiming a PARTIAL exemption, include a check in the amount o f $37.50 payable to the Client Security Fund. T CLAIM OF FULL OR PARTIAL EXEMPTION FROM THE CLIENT SECURITY FUND FEE T Enter applicable year A. I CLAIM A FULL EXEMPTION FOR THE CALENDAR YEAR FOR THE FOLLOWING REASON(S) ("X" all that apply) I have served or expect to serve on active duty in the armed forces of the United States for a period of more than six months during the calendar year noted above. I understand that if I should serve less than six months I must notify the office of the Client Security Fund and pay the full fee no later than thirty days after the end of the calendar year. I have retired from the practice of law in Connecticut and have filed the written notice of retirement pursuant to Practice Book Section 2-55 or 2-55A. I have resigned from the bar of the State of Connecticut pursuant to Practice Book Section 2-52. I have been disbarred. Enter applicable year B. I CLAIM A PARTIAL EXEMPTION FOR THE CALENDAR YEAR PURSUANT TO C.G.S. § 51-81d. I do not engage in the practice of law as an occupation AND have not and do not expect to earn more than $450 in legal fees or other compensation for services involving the practice of law during the calendar year noted above. I understand that if my circumstances change so that I do not qualify for the exemption for the year noted above, I must notify the Client Security Fund Committee and pay the balance of the fee. I have enclosed my check in the amount of $37.50 payable to the "Client Security Fund". I hereby certify that the information provided herein is true and correct. If any statements are willfully false, I understand that I am subject to discipline by the Superior Court. Signed (Attorney) Name of attorney (Print or type) Juris number Date American LegalNet, Inc. www.FormsWorkFlow.com