COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CONNECTICUT JUDICIAL BRANCH SUPERIOR COURT www.jud.state.ct.usAFFIDAVITRE: EXEMPT FUNDS:::::::Index No.AFFEXE COURT USE ONLYJD-CV-73 New 2-02 C.G.S ยง52-367b, P.A. 01-196Calendar No.INSTRUCTIONS Complete and present to the clerk of court where the action is pending.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)DOCKET NO.NAME OF CASE (FIRST-NAMED PLAINTIFF V. FIRST-NAMED DEFENDANT)Small Claims Area at:Housing Session at:G.A. at:ADDRESS OF COURT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .AFFIDAVIT RE: EXEMPT STATUS OF FUNDS Judicial District at:The undersigned duly deposes and says that he/she is thein theTHE PEOPLE OF THE STATE OF NEW YORK TO1. I am over the age of eighteen and believe in the obligation of an oath. 2. I believe that the judgment debtor's account contains funds which are not exempt from execution because: (Explain the facts on which you base your belief.)GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.3. The amount that I believe is not exempt is: $.I request a hearing on this matter. I hereby certify that the foregoing statements are true to the best of my knowledge and belief., one of the Justices of theCourt in Witness, Honorableday of, 20 County,SIGNED (Affiant)XDATESIGNED (Clerk, Commissioner of Superior Court, Notary Public) X(Attorney must sign above and type name below)Subscribed and sworn to before me on:COURT ORDER (For Court Use Only)FOR COURT USE ONLYHaving reviewed this affidavit, I find that:Attorney(s) forThe judgment creditor HAS demonstrated a reasonable belief that the judgment debtor's account contains funds which are not exempt from execution. The judgment creditor IS authorized to submit a written application to the clerk for a hearing on the exempt status of funds. The judgment creditor HAS NOT demonstrated a reasonable belief that the judgment debtor's account contains funds which are not exempt from execution. The judgment creditor IS NOT authorized to submit a written application to the clerk for a hearing on the exempt status of funds.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:BY (Judge of the Superior Court)DATEMobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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