AFFIDAVIT LOST BOND RECEIPT JD-CL-51 Rev. 7-14 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov ADA NOTICE 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. Docket number Instructions 1. Prepare on typewriter, electronically, or print legibly. 2. Submit the original to the clerk of court. Name of case (Plaintiff v. Defendant) Type of court Address of court (Number, street, town and zip code) Judicial District Your name (Affiant) Geographical Area number Housing Session Your address (Number, street, town, state and zip) Date Amount of cash bond Date posted Bond receipt number $ Affidavit Of Lost Bond Receipt The individual described above personally appeared before me and, after being duly sworn, deposes as follows: 1. I currently reside at the address indicated above and on the above date I posted a cash bond in the amount shown in connection with the case named above. 2. I have lost the original bond receipt which was presented to me at the time I posted the bond. In the event the original bond receipt is found I will not present it for payment. 3. The bond money has not been returned to me. I certify that the statements above are true to the best of my knowledge and belief. Identification Supplied Type Number X Signature of Affiant Subscribed and sworn to before me on: Date Signed (Clerk, Deputy Clerk, Commissioner of Superior Court, Notary Public) American LegalNet, Inc. www.FormsWorkFlow.com