Print or type name of person signingDistribution: Original 227 Court File Copy 1 227 Defendant Copy 2 227 Plaintiff Housing Session at Judicial District atAFFIDAVIT OF NONCOMPLIANCE WITH STIPULATION JD-HM-22 Rev. 5-19 P.B. 247 17-53 The undersigned hereby deposes and states the following: 1.I am over the age of eighteen years and I believe in the obligation of an oath. 2. I am the person ordered to receive the above-mentioned payment(s); or, I am familiar with the accounting/financial books and records of the entity ordered to receive the above-mentioned payments, and I have personal knowledge of the matters stated herein and the facts set forth are true and accurate to the best of my knowledge and belief. 3.On the above-mentioned date of judgment or court order, the defendant was ordered to pay use and occupancy and/or arrearage in the amount shown above, on or before the payment date(s) indicated. 4.To date, payment has not been received. 5.I therefore request that a Summary Process (Eviction) Execution for Possession issue. Notice To Defendant A Summary Process Execution will issue on the third business day after the filing of this affidavit with the court. If you object to the execution issuing, you must file an objection before the issuance of the execution with the clerk at the court address indicated above.Amount due:Amount due:Payment date(s)Payment date(s) FOR COURT USE ONLY File DateSTATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Address of court (Number, street, town and zip code) Docket Number Name of case Date of judgment or court order Use and occupancy Arrearage Mailing address (Number, street, town, state and zip code) Signed (Signature of filer) uCertification Date signed Telephone number hand on (date) to all attorneys and self-represented parties of record and to all parties who have not appeared in this matter and that written consent for electronic delivery was received from all attorneys and self-represented parties receiving electronic delivery. (If necessary, attach additional sheets with names, addresses and methods of delivery.)I certify that a copy of this document was or will immediately be mailed or delivered electronically or non-electronically or in Name and address of first attorney or party Name and address of second attorney or party Name and address of third attorney or party Name and address of fourth attorney or party Signed (Affiant) u Signed (Assistant Clerk, Notary, Commissioner of the Superior Court) Date signed Print or type name and title of person signing Subscribed and sworn to before me: On (date) 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. COURT USE ONLY AFFNWS *AFFNWS* Hand delivered Electronically delivered Mailed Hand delivered Electronically delivered Mailed Hand delivered Electronically delivered Mailed Hand delivered Electronically delivered Mailed American LegalNet, Inc. www.FormsWorkFlow.com