UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT APPLICATION FOR AND WRIT OF EXECUTION PROPERTY APPLICATION To the United States District Court for the District of Connecticut at a judgment entered on . Docket No. ( , Connecticut, in connection with ), Case name: NAME AND ADDRESS OF JUDGMENT CREDITOR(S) MAKING APPLICATION: NAME(S) AND ADDRESS(ES) OF JUDGMENT DEBTOR(S): AMOUNT OF JUDGMENT: $ AMOUNT OF COSTS: $ AMOUNT OF INTEREST (if applicable): $ TOTAL JUDGMENT AND COSTS: $ TOTAL PAID ON ACCOUNT: $ TOTAL UNPAID JUDGMENT: $ IS THIS A JUDGMENT ARISING OUT OF SERVICES PROVIDED AT A HOSPITAL? No Yes (If yes, see "Notice to Judgment Creditor or Attorney" section on page 2.) IS THIS A CONSUMER JUDGMENT? "Consumer Judgment" means a money judgment of less than $5,000 against a natural person resulting from a debt incurred primarily for personal, family, or household purposes. No Yes (If yes, has a stay of property execution been entered pursuant to an installment pay order?) Yes No IF A STAY OF PROPERTY EXECUTION HAS BEEN ENTERED, HAS THE JUDGMENT DEBTOR DEFAULTED ON AN INSTALLMENT PAYENT ORDER? No Yes (Specify) Signature of Attorney or Party Making Application. Date Printed Name Bar Number Street Address Phone Number City/State/Zip Email Address American LegalNet, Inc. www.FormsWorkflow.com (Rev. 5/13/08) INSTRUCTIONS FOR WRIT OF PROPERTY EXECUTION JUDGMENT CREDITOR OR ATTORNEY - Complete and print original. If judgment debtor is a natural person, attach copy of Exemption Form. NOTICE TO JUDGMENT CREDITOR OR ATTORNEY- Pursuant to Public Act 03-266, Section 9, in the case of a judgment arising out of services provided at a hospital, no application for a property execution shall be made until the court has (A) issued an order for installment payments in accordance with Gen. Stat. § 52-356d, (B) made a finding that the debtor has defaulted on payments under the order, and (C) lifted the mandatory stay concerning noncompliance or default. The court also shall decide whether to modify the installment payment plan, continue the installment payment plan, or lift the stay. MARSHAL - Make execution as directed in the “Execution” section. Make return on signed original within four months from the date this execution issued. If judgment debtor is a natural person, attach exemption form to copy(ies) of execution served. Complete Section II on exemption claim form. PERSON IN POSSESSION OF PROPERTY OF JUDGMENT DEBTOR WHO IS A NATURAL PERSON - Pursuant to Conn. Gen. Stat. § 52-356a, you are required to mail to the judgment debtor (indicated on reverse side) at his or her last known address, postage prepaid, a copy of this property execution and the attached property execution exemption claim form. Complete Section III on exemption claim form before mailing it to judgment debtor. Twenty days from the date of the service of this property execution, you must deliver to the marshal property owned by the judgment debtor in your possession or you must deliver to the proper officer payment of a debt owed by you to the judgment debtor. EXCEPT (1) If an exemption claim has been filed with the court you shall withhold delivery of the property or payment of the debt owed by you subject to the determination of the exemption claim by the court and (2) if the debt owed by you to the judgment debtor is not due at the expiration of the twenty days, you shall pay the amount to the marshal when the debt becomes due if it becomes due within four months after the date of issuance of this execution. PERSON IN POSSESSION OF PROPERTY OF JUDGMENT DEBTOR WHO IS NOT A NATURAL PERSON - Pursuant to Conn. Gen. Stat. § 52-356a, you are required to deliver to the marshal, property in your possession owned by the judgment debtor or pay to the marshal the amount of a debt owed by you to the judgment debtor, provided, if the debt owed by you is not yet payable, payment shall be made to the marshal when the debt becomes due within four months after the date of issuance of this execution American LegalNet, Inc. www.FormsWorkflow.com PROPERTY EXECUTION TO ANY PROPER OFFICER: Whereas on said date of Judgment the above-named Judgment Creditor(s) recovered a judgment against the Judgment Debtor(s) before the Court for the amount stated, as appears of record, whereof execution remains to be done. These are therefore, BY AUTHORITY OF THE UNITED STATES DISTRICT COURT TO COMMAND YOU: That of the nonexempt goods of said Judgment Debtor(s) within your precincts, you cause to be levied (the same being seized and sold as the law directs), paid and satisfied to said Judgment Creditor(s) the total unpaid amount of said judgment, plus your own fees in the following manner: You shall personally serve a copy of this execution on the judgment debtor, and if the judgment debtor is a natural person, a copy of the exemption claim form, and make demand for payment by the judgment debtor of all sums due under the money judgment. On failure of the judgment debtor to make immediate payment you are commanded to levy on nonexempt personal property of the judgment debtor, other than debts due from a banking institution or earnings, sufficient to satisfy the judgment as follows: If such nonexempt property is in the possession of the judgment debtor, you shall take such personal property into your possession as is accessible without breach of the peace. If the judgment debtor has left the state prior to service of this execution, or if the judgment debtor cannot be found with reasonable effort at the last known address in this state, you shall proceed with the levy after (1) making demand for payment at such last known address and on any agent or attorney of the judgment debtor of record with the United States District Court for the District of Connecticut and (2) making a reasonable effort to ascertain and provide notice of the execution at any forwarding address. A. If judgment debtor is a natural person: On failure of the judgment debtor to make immediate payment of all sums due under the money judgment, and upon your being unable to levy on nonexempt personal property of the judgment debtor in the judgment debtor's possession and, if the judgment debtor has left the state prior to the service of this execution, upon your being unable to obtain payment sufficient to satisfy the judgment by making demand for payment at the judgment debtor's last known address in this state and on any agent or attorney of the judgment debtor of record with the Clerk of the U. S. District Court for the District of Connecticut, you are also commanded to make demand upon any third person having possession of nonexempt personal property of the judgment debtor for payment to you, or to levy on any nonexempt personal property or debt due said judgment debtor sufficient to satisfy the total amount of judgment unpaid pursuant to Gen. Stat. 52-356a(4)(c). After having made such demand you are directed to serve two true and attested copies of this execution, together with the exemption claim form, with your doings endorsed thereon, on the third person upon whom such demand was made. B. If judgment debtor is not a natural person: On failure of the judgment debtor to make immediate payment of all sums due under the money judgment and upon your being unable to levy on nonexempt personal property of the judgment debtor in the judgment debtor's possession and, if the judgment debtor has left the state prior to the service of this execution, upon your being unable to obtain payment sufficient to satisfy the judgment by making demand for payment at the judgment debtor's last known address in this state and on any agent or attorney of the judgment debtor of record with the Clerk of the U. S. District Court for the District of Connecticut, you are also commanded to make demand upon any third person having possession of nonexempt personal property of the judgment debtor for payment to you or to levy on any nonexempt personal property or debt due said judgment debtor(s) sufficient to satisfy the total amount of the judgment unpaid pursuant to Gen. Stat. 52-356a(4)(c). HEREOF FAIL NOT, AND MAKE DUE RETURN OF THIS WRIT WITH YOUR DOINGS THEREON, ACCORDING TO LAW, WITHIN FOUR MONTHS HEREOF. NOTICE: THE JUDGMENT DEBTOR’S NONEXEMPT PERSONAL PROPERTY IS SUBJECT TO LEVY, SEIZURE AND SALE BY THE PROPER OFFICER PURSUANT TO THIS EXECUTION. DATED AT CONNECTICUT, THIS DAY OF , 20 . ROBERTA D. TABORA, CLERK BY: DEPUTY CLERK American LegalNet, Inc. www.FormsWorkflow.com RETURN OF SERVICE STATE OF CONNECTICUT : : COUNTY OF On the ss: : day of , 20 , then and there I duly served the foregoing application, order and execution on by leaving with or at the usual place of abode of a true and attested copy of the original application, order and execution. Attest: Proper Officer Title American LegalNet, Inc. www.FormsWorkflow.com