FORECLOSURE MEDIATION REQUEST JD-CV-93 Rev. 7-09 C.G.S. § 49-31l, P.A. 09-209 STATE OF CONNECTICUT SUPERIOR COURT JUDICIAL BRANCH www.jud.ct.gov FMREQ Instructions to Homeowner Applicant This form is for foreclosure cases with a return date from July 1, 2008 through June 30, 2009. If the return date in your case is after June 30, 2009, you must use the Foreclosure Mediation Certificate form (JD-CV-108). If you want to use the Foreclosure Mediation Program and the Return Date in your case is between July 1, 2008 and June 30, 2009: 1. Fill out this Request 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. If you were served with this Foreclosure Mediation Request form after you were served the Summons, you may file this Request and the Appearance form not more than 15 days after Type or Print Legibly Name of Case (Plaintiff on Summons vs. Defendant on Summons) Return Date (On upper right portion of Summons) this Foreclosure Mediation Request form was served on you or not more than 15 days after the return date on the Summons, whichever is later. 2. You must mail or deliver a copy of the completed Request form and the Appearance form to all parties of record (the plaintiff and all other defendants named on the Summons). 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 Yes Yes Yes Print Name of Person Signing No No No No Is it a one-to-four family residential property located in Connecticut? Are you the borrower? Is this a mortgage foreclosure? If you answered "No" to any of these questions, please do not submit this Request as you do not qualify for the Foreclosure Mediation Program. Date Signed I request foreclosure mediation in my case: Signed I certify that a copy of this Request was mailed or delivered to all counsel and self-represented (pro se) parties of record on (Date mailed or delivered): Signed (Attorney or self-represented party) Address (Number, street, town, state, zip code) Print Name of Person Signing Telephone Number Name and address of each party of record this notice was mailed or delivered to (All Plaintiffs, Attorneys, Law Firms and all other Defendants on Summons)* Name (Each party served) Address (Where party was served ) *If necessary, attach additional sheet with name of each party served and the address at which service was made. American LegalNet, Inc. www.FormsWorkFlow.com