FORECLOSURE MEDIATION CERTIFICATE JD-CV-108 Rev. 7-15 C.G.S. §§ 49-31k, 49-31l; P.A. 15-124 STATE OF CONNECTICUT SUPERIOR COURT JUDICIAL BRANCH www.jud.ct.gov Instructions to Homeowner Applicant 1. Use this form if the 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.jud.ct.gov) 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, and to all parties who have filed an appearance in the case. FMREQ *FMREQ* This form will be used to determine your eligibility for the Foreclosure Mediation Program. Type or Print Legibly Name of case (Plaintiff on Summons vs. Defendant on Summons) Return date (On upper right portion of Summons) Judicial District of (On upper left portion of Summons) Docket number (To be filled in by court staff) Your name Address (Number, street, town, state, zip code) Telephone number Business phone Cell phone ( ) ( ) ( ) A. If you are an individual, answer the following questions: 1. Do you own the property? 2. Do you live in the property? 3. Is it your primary residence? 4. Is it a 1, 2, 3 or 4 family residential property located in Connecticut? 5. Is this a mortgage foreclosure? 6. Are you a borrower on the note? Yes Yes Yes Yes Yes Yes No No No No No No If you are not a borrower on the note, but answered "yes" to questions one (1) through five (5) and you are the spouse or former spouse of a borrower, go to Section C, on Page 2. If you answered "yes" to questions one (1) through six (6) and another defendant in this case has requested or may request in Section C to participate in the Foreclosure Mediation Program as a Permitted Successor-in- Interest, who became the owner of the property as a result of divorce, legal separation, or a property settlement agreement related to a divorce or legal separation, go to Section D.1. OR B. If you are filing this on behalf of a religious organization, answer the following questions: Yes No 1. Does a religious organization own the property? 2. Is the property located in Connecticut? Yes No 3. Is the religious organization the borrower on the note? Yes No Yes No 4. Is the return date in the case on or after October 1, 2011? ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Continued on next page... Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com C. Permitted Successors-in-Interest If you are not a borrower on the note, but answered "yes" to questions one (1) through five (5) in Section A and you are the spouse or former spouse of a borrower, you may be able to participate in the Foreclosure Mediation Program as a Permitted Successor-in-Interest. Answer the following questions to help the Court determine if you qualify: 1. Are you a defendant in this case? Yes No 2. Is the return date in this case on or after October 1, 2015? Yes No 3. If you answered "yes" to one (1) and two (2), how did you become the owner of the property? (check the box that applies to you, if any) 3a. I became the only owner of the property when it was transferred to me from my deceased spouse's estate. 3b. I became the only owner of the property because my deceased spouse and I held joint title to the property. 3c. I became the owner of the property because it was transferred to me as a result of a divorce, legal separation, or a property settlement agreement related to a divorce or legal separation. If you checked 3c., go to Section D.2 and Section D.3. D. Consents If a Permitted Successor-in-Interest, who became the owner of the property as a result of divorce, legal separation, or a property settlement agreement related to a divorce or legal separation, has applied or may apply for the Foreclosure Mediation Program, you must complete this section to qualify for the Foreclosure Mediation Program: (check only the box(es) that apply) 1. If you answered "yes" to questions one (1) through six (6) in Section A and another defendant has requested or may request to participate in the Foreclosure Mediation Program as a Permitted Successor-inInterest, who became the owner of the property as a result of divorce, legal separation, or a property settlement agreement related to a divorce or legal separation, check this box to complete your consent: I consent to the plaintiff mortgagee's disclosure of my non-public personal financial information to the spouse or former spouse who qualifies as a Permitted Successor-in-Interest to the extent that the plaintiff mortgagee has that information. 2. If you answered "yes" to questions one (1) and two (2) in Section C, and checked box 3c., check this box to complete your consent: I consent to the plaintiff mortgagee's disclosure of my non-public personal financial information to all borrowers on this note, to the extent that the plaintiff mortgagee has that information. 3. If you answered "yes" to questions one (1) and two (2) in Section C, and checked box 3c., check this box to certify that all borrowers on the note have provided their consent: I certify that all borrowers on the note have agreed to allow the plaintiff mortgagee to disclose their nonpublic personal financial information to me, to the extent that the plaintiff mortgagee has that information, and that the borrowers have shown their consent by (check any box that applies): Submitting a Foreclosure Mediation Certificate containing their consent, or Giving documentation to the plaintiff mortgagee that allows for the full disclosure of the borrower's non-public personal financial information to me. Signed Print name of person signing Date signed Certification I certify that a copy of this document was or will immediately be mailed or delivered electronically or non-electronically on to all attorneys and self-represented parties of record and that written consent for electronic delivery (date) was received from all attorneys and self-represented parties of record who were or will immediately be electronically served. Name and address of each party and attorney that copy was or will immediately be mailed or delivered to* *If nec