EXEMPTION CLAIM FORM FINANCIAL INSTITUTION EXECUTION JD-CV-24A Rev. 2-15 C.G.S. 31-58(i), 52-321a, 52-350a, 52-352b, 52-361a, 52-367b, 29 U.S.C. 206(a)(1) SEE INSTRUCTIONS ON BACK/PAGE 2 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Name and address of Judgment Debtor or Attorney (To be completed by judgment creditor or attorney) To: MXMPEX *MXMPEX* Section 1 -- (To be completed by judgment creditor) Judicial District Name of case Housing Session Geographical Area Number Name and address of Court (Number, Street, Town and Zip Code) Name of Judgment Debtor Docket number Section 2 -- (To be completed by financial institution - see instructions on back/page 2) Name and address of financial institution to which exemption claim (if any) is to be returned Date of mailing to Judgment Debtor Amount and type of readily identifiable exempt funds not removed Last 4 Digits of the Account Number(s) Amount removed pursuant to execution Additional sheet(s) attached hereto and made a part hereof (if necessary). Section 3 -- Notice To Judgment Debtor As a result of a judgment entered against you, the attached execution has been issued against funds deposited by you in the financial institution named above. In compliance with this execution, the financial institution has removed the amount of money indicated above from the account(s) enumerated above. THE MONEY IN YOUR ACCOUNT(S) MAY BE EXEMPT FROM EXECUTION - The money in your account(s) may be protected from execution by state statutes or by other laws or regulations of this state or of the United States. A checklist and a description of the most common exemptions established by law are set forth below. HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW. If you wish to claim that the money in your account(s) is exempt by law from execution, you must fill out and sign before a proper official the Affidavit of Claim of Exemption below and mail or deliver this exemption claim form to the financial institution at the above address. This form must be received by the financial institution no later than 15 days from the DATE OF MAILING TO THE JUDGMENT DEBTOR indicated above. Upon receipt of this form the financial institution will forward it to the Superior Court and the court clerk will notify you and the judgment creditor of the date on which a hearing will be held by the court to determine the issues raised by your claim. SECTION 4 -- AFFIDAVIT OF CLAIM OF EXEMPTION ESTABLISHED BY LAW I, the judgment debtor named above, claim and certify under the penalty of false statement that the money in the above account is exempt by law from execution as follows: ("X" all that apply to the funds contained in this account) Social Security benefits (section 52-352b(g)) Private pension, trust, retirement, or medical savings Unemployment benefits (section 52-352b(g)) account payments (sections 52-321a, 52-352b(m)) Worker's Compensation benefits (section 52-352b(g)) Health or disability insurance payments (section 52-352b(e)) Veteran's benefits (section 52-352b(g)) An amount in the bank not to exceed $1000 (section 52-352b(r)) Public Assistance payments (section 52-352b(d)) Other claim of exempt funds (Explain basis for claim of exemption): Wages* (section 52-361a) Wages earned by a public assistance recipient under an incentive earnings or similar program (section 52-352b(d)) Amount claimed to be exempt if less than the entire amount: Court-ordered child support payments (section 52-352b(h)) Alimony and support other than child support* (section 52-352b(n)) *See Note Regarding Exemption for Wages and Alimony on back/page 2. Signed Complete mailing address of Judgment Debtor Date signed Telephone number Subscribed and sworn to before me on : Date At (Town) Signed (Notary Public, Commissioner of Superior Court) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Instructions To Financial Institution 1. Complete section 2 of this form and (1) send 2 copies of this form and the financial institution execution form to the judgment debtor and to any secured party that is party to a control agreement between the financial institution and such secured party under article 9 of title 42a pursuant to section 52-367b of the General Statutes and (2) mail notice to judgment debtor as required by 31CFR212.6 and 212.7. 2. If this claim of exemption is returned completed, fill out section 4 of this form and mail, within two business days, to the issuing clerk's office at the address of court indicated on the front side. See additional instructions on the financial institution execution form. To Clerk 1. Attach this form to each financial institution execution issued in a civil or family matter against a judgment debtor that is a natural person. 2. Deliver the execution along with this form to the judgment creditor requesting the execution. 3. If judgment debtor completes and returns this form claiming an exemption, enter the appearance of the judgment debtor with address set forth on page 1. 4. Set matter down for short calendar hearing. 5. Complete section 7 below. 6. Send file-stamped copy of this form to judgment debtor and judgment creditor. 7. After hearing, send copy of any order entered to the financial institution. Note Regarding Exemption For Wages And Alimony The amount of wages and alimony that may be subject to levy or other withholding for payment of a judgment is the lesser of (1) twentyfive per cent of the individual's disposable earnings for that week, or (2) the amount by which the individual's disposable earnings for that week exceed forty times the higher of (A) the federal minimum hourly wage under Section 6(a)(1) of the Fair Labor Standards Act of 1938, U.S.C. tit. 29, Section 206(a)(1), or (B), the state minimum hourly wage under subsection (i) of Section 31-58, in effect at the time the earnings are payable. Section 52-350a(4) of the Connecticut General Statutes defines "disposable earnings" as that part of the earnings of an individual remaining after the deduction from those earnings of amounts required to be withheld for payment of federal income and employment taxes, normal retirement contributions, union dues and initiation fees, group life insurance premiums, health insurance premiums and federal tax levies. Section 5 -- Proper Officer Must Complete This Section Name and title of proper officer Date of service on financial institution Telephone number Section 6 -- (To be completed by financial institution upon return of exemption claim form) Da