Noncompliance With Stipulation
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1JD-HM-22: Affidavit Re:
Noncompliance with Stipulation
STATE OF CONNECTICUT
AFFIDAVIT RE:
SUPERIOR COURT
NONCOMPLIANCE WITH STIPULATION
JD-HM-22 Rev. 10-08 Pr. Bk. § 17-53
Geographical
Return Date
Judicial
Housing
Area Number
District at
Session at
Address of Court (Number, street, town and zip code)
Docket Number
Name of Case (First-Named Plaintiff vs. First-Named Defendant)
Date of Judgment
Payment
Date(s)
Use & Occupancy
Amount Due:
Payment
Date(s)
Arrearage
Amount Due:
The undersigned duly deposes and says that I am the plaintiff or plaintiff's attorney in the above-entitled matter and states
as follows:
1. I am over the age of eighteen years and I believe in the obligation of an oath.
2. On the above-mentioned date of judgment, the defendant was ordered to pay use and occupancy
and/or an arrearage to the plaintiff/plaintiff's attorney in the amount shown above. This payment was
to be made on or before the payment date indicated.
3. To date, this payment has not been received.
4. I am therefore requesting that a Summary Process (Eviction) Execution for Possession issue.
Signed (Plaintiff/Plaintiff's Attorney)
Signed (Clerk/Commissioner of Superior Court)
Subscribed and sworn to before me on:
Date
Certification
I hereby certify that a copy of the above was mailed or
Date Copy or Copies Mailed or Delivered
delivered to all counsel and self-represented parties of record on:
Signed (Individual attorney or self-represented party)
Address (Number, street, town, and zip code)
Name and Address of Each Party Served (If necessary, attach additional sheet)
FOR COURT USE ONLY
File Date
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.
AFFIDAVIT RE:
Distribution:
Original — Court File
Copy 1 — Defendant
Copy 2 — Plaintiff
NONCOMPLIANCE WITH STIPULATION
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