SECRETARY OF THE STATE OF CONNECTICUT MAILING ADDRESS: COMMERCIAL RECORDING DIVISION, CONNECTICUT SECRETARY OF THE STATE, P.O. BOX 150470, HARTFORD, CT 06115-0470 DELIVERY ADDRESS: COMMERCIAL RECORDING DIVISION, CONNECTICUT SECRETARY OF THE STATE, 30 TRINITY STREET, HARTFORD, CT 06106 PHONE: 860-509-6002 WEBSITE: www.concord-sots.ct.gov JUDGMENT LIEN CERTIFICATE USE INK. COMPLETE ALL SECTIONS. PRINT OR TYPE. ATTACH 81/2 X 11 SHEETS IF NECESSARY. FILING PARTY (CONFIRMATION WILL BE SENT TO THIS ADDRESS): CUSTOMER ID: NAME: ADDRESS: FILING FEE: $50 MAKE CHECKS PAYABLE TO "SECRETARY OF THE STATE" CITY: STATE: EMAIL: 1. JUDGMENT DEBTORS FULL LEGAL NAME ZIP: 1A. ORGANIZATION'S NAME 1B. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME 1C. MAILING ADDRESS: ADDRESS: MIDDLE SUFFIX OR CITY: STATE: ZIP: COUNTRY: 2. ADDITIONAL JUDGMENT DEBTORS FULL LEGAL NAME 2A. ORGANIZATION'S NAME 2B. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME 2C. MAILING ADDRESS: ADDRESS: MIDDLE SUFFIX OR CITY: STATE: ZIP: COUNTRY: PAGE 1 OF 2 FORM UJPERS-1-1.1 Rev. 7/2013 American LegalNet, Inc. www.FormsWorkFlow.com 3. JUDGMENT CREDITORS FULL LEGAL NAME 3A. ORGANIZATION'S NAME 3B. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME 3C. MAILING ADDRESS: ADDRESS: MIDDLE SUFFIX OR CITY: STATE: ZIP: COUNTRY: 4. ADDITIONAL JUDGMENT CREDITORS FULL LEGAL NAME 4A. ORGANIZATION'S NAME 4B. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME 4C. MAILING ADDRESS: ADDRESS: MIDDLE SUFFIX OR CITY: STATE: ZIP: COUNTRY: 5. COURT IN WHICH JUDGMENT WAS RENDERED 6. DATE OF JUDGMENT 7. ORIGINAL JUDGMENT AMOUNT 8. AMOUNT DUE 9. PERSONAL PROPERTY ON WHICH LIEN IS PLACED 10. JUDGMENT CREDITOR SIGNATURE: 11. DATE: FORM UJPERS-1-1.1 Rev. 7/2013 PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com