FORECLOSURE MEDIATION -- SUPPLEMENTAL INFORMATION BY PARTY JD-CV-133 New 7-13 P.A. 13-136 STATE OF CONNECTICUT COURT USE ONLY SUPERIOR COURT www.jud.ct.gov FMSUPIN *FMSUPIN* 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. 1. Type or print legibly. 2. Fill in any supplemental information that you wish to include below. DO NOT attach any documents to this form or include any personal identifying information, such as loan numbers, bank account numbers, etc. 3. File this form with the Court not later than 5 business days after receipt of the Mediator's Report. Name of Case (Plaintiff v. Defendant) Judicial District of Instructions to person filing this form ADA NOTICE Docket number Return date The following is supplemental information to the Mediator's Report, dated : Information submitted by Signed plaintiff defendant Print name Date signed Telephone number (with area code) Address (Number, street, town, state, zip 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