STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov APPLICATION FOR REAL ESTATE BOND JD-CR-109 Rev. 11-08 C.G.S. § 54-66. Pr. Bk. Secs. 38-9, 43-2 State of Connecticut vs. Judicial District Geographic Area At I, the undersigned, having been first duly sworn, make answer to the following questions: Name Residence Address of Real Estate Being Pledged (Number, street, town, state and zip code) 1. Has a notice of lien containing the terms of the bond been properly filed, pursuant to C.G.S. §54-66, on a form prescribed by the Office of the Chief Court Administrator with the town clerk of the town in which the property is located? No Yes (Attach proof of such filing) 2. Have you obtained an independent appraisal by a licensed real estate appraiser prepared within ninety (90) days of this application as to the present fair market value of the property? No Yes (Attach appraisal) Appraiser's statement of present fair market value: $ 3. Have you obtained from an attorney a current certificate of title containing a list of all encumbrances of record, including the notice of lien in question 1? No Yes (Attach the certificate of title) 4. Are there any encumbrances of record which were filed prior to the notice of lien required in question 1? (If yes, list each encumbrance and the amount thereof) No Yes Amount Encumbrance 5. Does any other person have any interest in this property? No Yes (If yes, list all owners) 6. What is your ownership interest in this property? 7. Are there any present tax liabilities? No 8. Do you know of any other encumbrances or assessments? (If yes, list each encumbrance or assessment and the amount) No Yes (If yes, in what amount?) Yes Encumbrance/Assessment Amount 9. Is the property mortgaged? No Amount of Mortgage What Is Your Equity In The Property? Yes (If yes, to whom?) 10. Is this property pledged as security for any other bonds or for any other purpose? (If yes, list each pledge and the amount thereof) No Yes Pledge Amount 11. Is there now any attachment, or suit in law or equity, pending, tending to affect your title? STATE OF CONNECTICUT COUNTY OF Personally appeared to the truth thereof. } No Yes (If yes, describe below) Affiant ss. , 20 . who subscribed to the foregoing application and made oath Assistant Clerk INSTRUCTIONS TO AFFIANT: A separate affidavit must be signed by each owner of the property being pledged. American LegalNet, Inc. www.FormsWorkflow.com