FORECLOSURE MEDIATION -- PETITION FOR REINCLUSION JD-CV-136 New 8-13 P.A. 13-136, Sec. 2 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov COURT USE ONLY FMREINC *FMREINC* 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. Instructions to person filing this form 1. Type or print legibly and file with the Court. 2. DO NOT attach any documents to this form or include any personal identifying information, such as loan numbers, bank account numbers, etc. ADA NOTICE Name of case (Plaintiff v. Defendant) Docket number Judicial District of Return date I request reinclusion in the Foreclosure Mediation Program for the following reason(s): Signed Address (Number, street, town, state, zip code) Print name Date signed Telephone number (with area code) Certification to all attorneys I certify that a copy of this document was mailed or delivered electronically or non-electronically on (date) and self-represented parties of record and that written consent for electronic delivery was received from all attorneys and self-represented parties receiving electronic delivery. Name and address of each party and attorney that copy was mailed or delivered to* *If necessary, attach additional sheet or sheets with name and address which the copy was mailed or delivered to. Signed (Signature of filer) Print or type name of person signing Date signed Telephone number u Mailing address (Number, street, town, state and zip code) American LegalNet, Inc. www.FormsWorkFlow.com