EXEMPTION CLAIM FORM PROPERTY EXECUTION STATE OF CONNECTICUT JD-CV-5b Rev. 8-06 C.G.S. 52-321a, 52-352b, 52-361a, 52-361b CLOEXM SUPERIOR COURT www.jud.ct.gov NAME AND MAILING ADDRESS OF JUDGMENT DEBTOR OR ATTORNEY (To be completed by judgment creditor or judgment creditor's attorney) INSTRUCTIONS TO JUDGMENT CREDITOR OR JUDGMENT CREDITOR'S ATTORNEY: Complete section I below and follow instructions on form JD-CV-5. TO PROPER OFFICER: Complete section II below and follow instructions on form JC-CV-5. TO THIRD PERSON: Complete section III below and follow instructions on form JD-CV-5. TO JUDGMENT DEBTOR: Read section IV below and complete section V if applicable. SECTION I (Must be completed by judgment creditor or judgment creditor's attorney) G.A. ADDRESS OF COURT (Number, street, town, zip code) J.D. HOUSING SESSION NAME OF CASE DOCKET NO. NAME OF JUDGMENT DEBTOR SECTION II (Must be completed by proper officer) DATE OF SERVICE OF EXECUTION NAME AND ADDRESS OF PROPER OFFICER NAME AND ADDRESS OF THIRD PERSON SERVED WITH EXECUTION (if any) TELEPHONE NO. (if known) SECTION III (Must be completed by third person served with execution (if any)) DATE EXECUTION MAILED TO JUDGMENT DEBTOR SECTION IV NOTICE TO JUDGMENT DEBTOR As a result of a judgment entered against you the attached execution has been issued against your personal property. SOME OF YOUR PERSONAL PROPERTY MAY BE EXEMPT FROM EXECUTION -- Certain classes of personal property may be protected from execution by state statutes or other laws or regulations of this state or of the United States. A checklist and description of the most common classes of personal property of a natural person exempt from execution are set forth on page 2 of this form. HOW TO CLAIM AN EXEMPTION ESTABLISHED BY LAW -- If you wish to claim that the property levied on by the levying officer is exempt by law from execution you must fill out and sign the Claim of Exemption on page 2 of this form and return this exemption claim form to the clerk of the Superior court at the above address. The form must be received by the clerk of the Superior Court within 20 days after levy on the property. Upon receipt of this form, 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. RIGHT TO REQUEST INSTALMENT PAYMENT ORDER -- Pursuant to section 52-356d of the general statutes, if you are a consumer judgment debtor, you may seek to have the court issue an instalment payment order with a provision that compliance with the order prevents a levy on your property. An instalment payment order is an order of the court that you pay a weekly amount to the judgment creditor until the judgment is satisfied. "Consumer Judgment" means a money judgment of less than five thousand dollars against a natural person resulting from a debt or obligation incurred primarily for personal, family, or household purposes. SETTING ASIDE THE JUDGMENT -- If the judgment was rendered against you because of your failure to appear in court, you may, pursuant to section 52-212 of the general statutes, within four months of the date judgment was rendered and upon belief that you have reasonable cause, move the court to set aside the judgment rendered against you. FOR COURT USE ONLY PAGE 1 OF 2 EXEMPTION CLAIM FORM American LegalNet, Inc. www.FormsWorkflow.com SECTION V CLAIM OF EXEMPTION ESTABLISHED BY LAW I, the judgment debtor, hereby claim and certify under penalty of false statement that the property described below is exempt from execution as follows: NAME AND ADDRESS OF PERSON HOLDING PROPERTY TELEPHONE NO. PROPERTY CLAIMED TO BE EXEMPT DESCRIBE BASIS FOR EXEMPTION AS ESTABLISHED BY LAW COMPLETE MAILING ADDRESS OF JUDGMENT DEBTOR TELEPHONE NO. SIGNED (Judgment debtor) DATE SIGNED SECTION VI DATE OF HEARING NOTICE OF HEARING ON EXEMPTION/MODIFICATION CLAIM TIME OF HEARING COURTROOM NO. __.M. BY THE ASSISTANT CLERK SECTION VII ORDER OF COURT ORDERED that the following item(s) are exempt from execution: SIGNED (Judge, Magistrate, Assistant Clerk) DATE SIGNED BY ORDER OF THE COURT CHECKLIST AND DESCRIPTION OF COMMON EXEMPTIONS ALLOWED BY LAW (C.G.S. § 52-352b) (a) Necessary apparel, bedding, foodstuffs, household furniture and appliances; (b) Tools, books, instruments, farm animals and livestock feed, which are necessary to the exemptioner in the course of his or her occupation, profession, farming operation or farming partnership; (c) Burial plot for the exemptioner and his or her immediate family; (d) Public assistance payments and any wages earned by a public assistance recipient under an incentive earnings or similar program; (e) Health and disability insurance payments; (f) Health aids necessary to enable the exemptioner to work or to sustain health; (g) Worker's compensation, social security, veterans and unemployment benefits; (h) Court approved payments for child support; (i) Arms and military equipment, uniforms or musical instruments owned by any member of the militia or armed forces of the United States; (j) One motor vehicle to the value of one thousand five hundred dollars, provided such value shall be determined as the fair market value of the motor vehicle less the amount of all liens and security interests which encumber it. (k) Wedding and engagement rings; (l) Residential utility deposits for one residence and one residential security deposit; (m) Any assets or interests of an exemptioner in, or payments received by the exemptioner from, a plan or arrangement described in section 52-321a; (n) Alimony and support, other than child support, but only to the extent that wages are exempt from execution under general statute section 52-361a; (o) An award under a crime reparations act; (p) All benefits allowed by any association of persons in this state towards the support of any of its members incapacitated by sickness or infirmity from attending to his usual business; and (q) All moneys due the exemptioner from any insurance company on any insurance policy issued on exempt property, to the same extent that the property was exempt. (r) Any interest of the exemptioner in any property not to exceed in value one thousand dollars; (s) Any interest of the exemptioner not to exceed in value four thousand dollars in any accrued dividend or interest under, or loan value of, any unmatured life insurance contract owned by the exemptioner under which the insured is the exemptioner or an individual of whom the exemptioner is a dependent; and (t) The homestead of the exemptioner to the value of seventy-five thousand dollars or, in the case of a money judgment arising out of services provided at a hospital, to the value of one hundred twenty-five thousand dollars, provided value shall be determined as the fair market value of the real property less the amount of any statutory or consensual lien which encumbers it. (u) Irrevocable transfers of money to an account held by a bona fide nonprofit debt adjuster licensed pursuant to sections 36a-655 to 36a-665 inclusive for the benefit of creditors of the exemptioner. JD-CV-5b (back/page 2) Rev. 8-06 PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkflow.com