STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov NOTICE OF APPLICATION FOR PREJUDGMENT REMEDY/CLAIM FOR HEARING TO CONTEST APPLICATION OR CLAIM EXEMPTION COURT USE ONLY CLPJRHG CLPJRA Contest PJR Application Application For PJR (If Section III Completed) INSTRUCTIONS TO PLAINTIFF/APPLICANT SUPERIOR COURT 1.Complete section I in connection with all prejudgment remedies EXCEPT ex parte prejudgment remedies and submit to the Clerk along with your application and other required documents. 2.Upon receipt of signed order for hearing from clerk, serve this form on defendant(s) with other required documents. JD-CV-53 Rev. 7-01 C.G.S. §§ 52-278c et seq. SECTION I - CASE INFORMATION (To be completed by Plaintiff/Applicant) Judicial District Housing Session COURT ADDRESS G.A. No. Has a temporary restraining order been requested? NO YES AMOUNT, LEGAL INTEREST, OR PROPERTY IN DEMAND, EXCLUSIVE OF INTEREST AND COSTS IS ("X" one of the following) LESS THAN $2500 NAME OF CASE (First-named plaintiff vs. First-named defendant) $2500 THROUGH $14,999.99 $15,000 OR MORE SEE ATTACHED FORM JD-CV-67 FOR CONTINUATION OF PARTIES CASE TYPE (From Judicial Branch code list) MAJOR: MINOR: C ("X" if applicable) NO. COUNTS L P J R A CLAIMING OTHER RELIEF IN ADDITION TO OR IN LIEU OF MONEY DAMAGES NAME AND ADDRESS OF PLAINTIFF/APPLICANT (Person making application for Prejudgment Remedy) (No., street, town and zip code) NAME(S), ADDRESS(ES) AND TELEPHONE NO(S). OF DEFENDANT(S) AGAINST WHOM PREJUDGMENT REMEDY IS SOUGHT (No., street, town and zip code) (Attach additional sheet if necessary) NAME AND ADDRESS OF ANY THIRD PERSON HOLDING PROPERTY OF DEFENDANT WHO IS TO BE MADE A GARNISHEE BY PROCESS PREVENTING DISSIPATION NAME AND ADDRESS OF ATTORNEY, LAW FIRM OR PLAINTIFF IF PRO SE (No., street, town and zip code) FOR THE PLAINTIFF(S) ENTER THE APPEARANCE OF: TELEPHONE NO. JURIS NO. (If atty. or law firm) SIGNED DATE SIGNED SECTION II - NOTICE TO DEFENDANT You have rights specified in the Connecticut General Statutes, including Chapter 903a, that you may wish to exercise concerning this application for a prejudgment remedy. These rights include the right to a hearing: (1) to object to the proposed prejudgment remedy because you have a defense to or set-off against the action or a counterclaim against the plaintiff or because the amount sought in the application for the prejudgment remedy is unreasonably high or because payment of any judgment that may be rendered against you is covered by any insurance that may be available to you; (2) to request that the plaintiff post a bond in accordance with section 52-278d of the General Statutes to secure you against any damages that may result from the prejudgment remedy; (3) to request that you be allowed to substitute a bond for the prejudgment remedy sought; and (4) to show that the property sought to be subjected to the prejudgment remedy is exempt from such a prejudgment remedy. You may request a hearing to contest the application for a prejudgment remedy, assert any exemption or make a request concerning the posting or substitution of a bond in connection with the prejudgment remedy. The hearing may be requested by any proper motion or by completing section III below and returning this form to the superior court at the Court Address listed above. You have a right to appear and be heard at the hearing on the application to be held at the above court location on: DATE TIME COURTROOM M. SECTION III - DEFENDANT'S CLAIM AND REQUEST FOR HEARING (To be completed by Defendant) I, the defendant named below, request a hearing to contest the application for prejudgment remedy, claim an exemption or request the posting or substitution of a bond. I claim: ("X" the appropriate boxes) that the amount sought in the application for prejudgment remedy is unreasonably high. that any judgment that may be rendered is adequately secured by insurance. a defense, counterclaim, set-off, or exemption. C L P J R H G FOR COURT USE ONLY that I be allowed to substitute a bond for the prejudgment remedy. that the plaintiff be required to post a bond to secure me against any damages that may result from the prejudgment remedy. I certify that a copy of the above claim was mailed/delivered to the Plaintiff or the Plaintiff's attorney on the Date Mailed/Delivered shown below. DATE COPY(IES) MAILED/DELIVERED SIGNED (Defendant) DATE SIGNED DOCKET NO. TYPE OR PRINT NAME AND ADDRESS OF DEFENDANT PJR CV NAME OF EACH PARTY SERVED* ADDRESS AT WHICH SERVICE WAS MADE* *If necessary, attach additional sheet with names of each party served and the address at which service was made. American LegalNet, Inc. www.FormsWorkflow.com