STATE OF CONNECTICUT SUPERIOR COURT JUDICIAL BRANCH www.jud.ct.gov FORECLOSURE MEDIATION CERTIFICATE JD-CV-108 New 7-09 P.A. 09-209 FMREQ Instructions to Homeowner Applicant 1. Use this form if return date in your case is on or after July 1, 2009. 2. Fill out this Certificate form and an Appearance form, JD-CL-12 (available at the courthouse or online at www.jud2.ct.gov/webforms) and file them with the court not more than 15 days after the return date on the Summons. 3. You must mail or deliver a copy of this completed Certificate form to the plaintiff's attorney, or to the plaintiff if the plaintiff is not represented by an attorney. Type or Print Legibly Name of case (Plaintiff on Summons vs. Defendant on Summons) Return date (On upper right portion of Summons) Docket number (To be filled in by court staff) Judicial District of (On upper left portion of Summons) Homeowner(s) Information Your name(s) Address (Number, street, town, state, zip code) Telephone number ) ( Business phone ( ) Cell phone ( ) Is this property your primary residence? Yes No Do you occupy the property? Yes No Is it a 1, 2, 3 or 4 family residential property located in Connecticut? Yes No Are you the borrower? Yes No Is this a mortgage foreclosure? Yes No Signed Print name of person signing Date signed Name and address of each party (plaintiff's attorney, or the plaintiff if the plaintiff is not represented by an attorney) this Certificate was mailed or delivered to:* Name (Of each party (plaintiff's attorney, or the plaintiff if the plaintiff is not represented Address (At which copy was mailed or delivered ) by an attorney) copy was mailed or delivered to) *If necessary, attach an additional sheet or sheets with the name of each party (plaintiff's attorney, or the plaintiff if the plaintiff is not represented by an attorney) and the address at which the copy was mailed or delivered to. I certify that a copy of this Certificate was mailed or delivered to the plaintiff's attorney, or to the plaintiff if the plaintiff is not represented by an attorney, on (Date mailed or delivered): Signed (Attorney or self-represented party completing form) Print name of person signing Telephone number Address (Number, street, town, state, zip code) American LegalNet, Inc. www.FormsWorkFlow.com