STATE OF CONNECTICUT AFFIDAVIT RE: NONCOMPLIANCE WITH STIPULATION SUPERIOR COURT www.jud.ct.gov JD-HM-22 Rev. 10-08 Pr. Bk. § 17-53 Judicial District at Housing Session at Return Date Geographical Area Number Address of Court (Number, street, town and zip code) Docket Number Name of Case (First-Named Plaintiff vs. First-Named Defendant) Date of Judgment Use & Occupancy Amount Due: Payment Date(s) Arrearage Amount Due: Payment Date(s) The undersigned duly deposes and says that I am the plaintiff or plaintiff's attorney in the above-entitled matter and states as follows: 1. I am over the age of eighteen years and I believe in the obligation of an oath. 2. On the above-mentioned date of judgment, the defendant was ordered to pay use and occupancy and/or an arrearage to the plaintiff/plaintiff's attorney in the amount shown above. This payment was to be made on or before the payment date indicated. 3. To date, this payment has not been received. 4. I am therefore requesting that a Summary Process (Eviction) Execution for Possession issue. Signed (Plaintiff/Plaintiff's Attorney) Signed (Clerk/Commissioner of Superior Court) Subscribed and sworn to before me on: Date Certification I hereby certify that a copy of the above was mailed or delivered to all counsel and self-represented parties of record on: Signed (Individual attorney or self-represented party) Date Copy or Copies Mailed or Delivered Address (Number, street, town, and zip code) Name and Address of Each Party Served (If necessary, attach additional sheet) FOR COURT USE ONLY File Date Notice To Defendant A Summary Process Execution will issue on the third business day after the filing of this affidavit with the court. If you object to the execution issuing, you must file an objection before the issuance of the execution with the clerk at the court address indicated above. Distribution: Original — Court File Copy 1 — Defendant Copy 2 — Plaintiff AFFIDAVIT RE: NONCOMPLIANCE WITH STIPULATION American LegalNet, Inc. www.FormsWorkflow.com