Form JD-HM-22 "Affidavit of Noncompliance With Stipulation" - Connecticut

What Is Form JD-HM-22?

This is a legal form that was released by the Connecticut Superior Court - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Connecticut Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-HM-22 by clicking the link below or browse more documents and templates provided by the Connecticut Superior Court.

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Download Form JD-HM-22 "Affidavit of Noncompliance With Stipulation" - Connecticut

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AFFIDAVIT OF NONCOMPLIANCE
COURT USE ONLY
STATE OF CONNECTICUT
WITH STIPULATION
SUPERIOR COURT
AFFNWS
www.jud.ct.gov
JD-HM-22
Rev. 7-19
P.B. § 17-53
*AFFNWS*
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
Judicial
Housing
District at
Session at
Address of court (Number, street, town and zip code)
Name of case
Date of judgment
or court order
Use and occupancy
Amount due:
Payment date(s)
Arrearage
Amount due:
Payment date(s)
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.
Print or type name and title of person signing
Date signed
Signed (Affiant)
u
On (date)
Subscribed and
Signed (Assistant Clerk, Notary, Commissioner of the Superior Court)
sworn to before me:
Certification
I certify that a copy of this document was or will immediately be mailed or delivered electronically or non-electronically or in
hand on
(date) to all attorneys and self-represented parties of record, 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.)
Name and address of first attorney or party
Hand delivered
Mailed
Electronically delivered
Name and address of second attorney or party
Hand delivered
Mailed
Electronically delivered
Name and address of third attorney or party
Hand delivered
Mailed
Electronically delivered
Name and address of fourth attorney or party
Hand delivered
Mailed
Electronically delivered
Print or type name of person signing
Date signed
Signed (Signature of filer)
u
Mailing address (Number, street, town, state and zip code)
Telephone number
FOR COURT USE ONLY
Notice To Defendant
File Date
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.
Distribution:
Original — Court File
Copy 1 — Defendant
Copy 2 — Plaintiff
Print Form
Reset Form
AFFIDAVIT OF NONCOMPLIANCE
COURT USE ONLY
STATE OF CONNECTICUT
WITH STIPULATION
SUPERIOR COURT
AFFNWS
www.jud.ct.gov
JD-HM-22
Rev. 7-19
P.B. § 17-53
*AFFNWS*
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
Judicial
Housing
District at
Session at
Address of court (Number, street, town and zip code)
Name of case
Date of judgment
or court order
Use and occupancy
Amount due:
Payment date(s)
Arrearage
Amount due:
Payment date(s)
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.
Print or type name and title of person signing
Date signed
Signed (Affiant)
u
On (date)
Subscribed and
Signed (Assistant Clerk, Notary, Commissioner of the Superior Court)
sworn to before me:
Certification
I certify that a copy of this document was or will immediately be mailed or delivered electronically or non-electronically or in
hand on
(date) to all attorneys and self-represented parties of record, 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.)
Name and address of first attorney or party
Hand delivered
Mailed
Electronically delivered
Name and address of second attorney or party
Hand delivered
Mailed
Electronically delivered
Name and address of third attorney or party
Hand delivered
Mailed
Electronically delivered
Name and address of fourth attorney or party
Hand delivered
Mailed
Electronically delivered
Print or type name of person signing
Date signed
Signed (Signature of filer)
u
Mailing address (Number, street, town, state and zip code)
Telephone number
FOR COURT USE ONLY
Notice To Defendant
File Date
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.
Distribution:
Original — Court File
Copy 1 — Defendant
Copy 2 — Plaintiff
Print Form
Reset Form