CONNECTICUT JUDICIAL BRANCH AFFIDAVIT RE: EXEMPT FUNDS COURT USE ONLY SUPERIOR COURT AFFEXE www.jud.ct.gov JD-CV-73 New 2-02 C.G.S §52-367b, P.A. 01-196 INSTRUCTIONS Complete and present to the clerk of court where the action is pending. DOCKET NO. NAME OF CASE (FIRST-NAMED PLAINTIFF V. FIRST-NAMED DEFENDANT) Judicial District at: Small Claims Area at: Housing Session at: G.A. at: ADDRESS OF COURT AFFIDAVIT RE: EXEMPT STATUS OF FUNDS The undersigned duly deposes and says that he/she is the in the 1. I am over the age of eighteen and believe in the obligation of an oath. 2. I believe that the judgment debtor's account contains funds which are not exempt from execution because: (Explain the facts on which you base your belief.) 3. The amount that I believe is not exempt is: $ . I request a hearing on this matter. I hereby certify that the foregoing statements are true to the best of my knowledge and belief. SIGNED (Affiant) Subscribed and sworn to before me on: DATE X SIGNED (Clerk, Commissioner of Superior Court, Notary Public) X COURT ORDER (For Court Use Only) FOR COURT USE ONLY Having reviewed this affidavit, I find that: The judgment creditor HAS demonstrated a reasonable belief that the judgment debtor's account contains funds which are not exempt from execution. The judgment creditor IS authorized to submit a written application to the clerk for a hearing on the exempt status of funds. The judgment creditor HAS NOT demonstrated a reasonable belief that the judgment debtor's account contains funds which are not exempt from execution. The judgment creditor IS NOT authorized to submit a written application to the clerk for a hearing on the exempt status of funds. BY (Judge of the Superior Court) DATE American LegalNet, Inc. www.FormsWorkflow.com