Form REGF-05 "Application for Reimbursement From the Real Estate Guaranty Fund" - Connecticut

What Is Form REGF-05?

This is a legal form that was released by the Connecticut State Department of Consumer Protection - 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 May 1, 2005;
  • The latest edition provided by the Connecticut State Department of Consumer Protection;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form REGF-05 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Consumer Protection.

ADVERTISEMENT
ADVERTISEMENT

Download Form REGF-05 "Application for Reimbursement From the Real Estate Guaranty Fund" - Connecticut

1326 times
Rate (4.3 / 5) 80 votes
For Official Use Only
REGF-05 Rev.5/05
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
R E A L E S T A T E C O M M I S S I O N
Telephone: (860) 713-6150
APPLICATION FOR REIMBURSEMENT FROM THE
REAL ESTATE GUARANTY FUND
I
: In accordance with 20-324a-20-324j; Any person aggrieved by any action of a real estate broker, real
NSTRUCTIONS
estate salesperson or unlicensed employee of a broker by reason of the embezzlement of money or property or money
or property unlawfully obtained from any person by false pretenses, artifice, trickery or forgery or by reason of any
fraud, misrepresentation or deceit may recover damages upon approval.
Application for reimbursement from the guaranty fund must be submitted within two years of final determination or
expiration of time for appeal in connection with any judgment. The maximum amount paid to each consumer is
$25,000.
You must provide the following documentation to substantiate your claim:
1. Listing agreement or real estate contract agreement or contract used for judgment.
2. CERTIFIED copy of the court judgment;
3. Copies of Writ of execution (BOTH Bank and Property) including statement from officer executing same;
(not applicable to Small Claims Judgments) and;
4. If bankruptcy discharge, a certified copy of the Discharge of Debtor Notice including the schedule in which
you are listed as a creditor, and the amount of damages.
Return your completed application to:
Department of Consumer Protection, Real Estate Guaranty Fund, 165 Capitol Avenue, Hartford, CT 06106.
CONSUMER INFORMATION:
Name
Court Docket #:
Address (No. & Street, City, State, Zip Code)
Home Telephone Number (With Area Code)
Work Telephone Number (With Area Code)/Email Address
REAL ESTATE BROKER / REAL ESTATE SALESPERSON INFORMATION:
Name
License Number:
Business Name
Work Telephone Number
(With Area Code)
Address (No. & Street, City, State, Zip Code)/Email Address
Date Contract was signed:
/
/
(Attach copy of contract)
1. Is the consumer a spouse or personal representative of the judgment debtor / defendant a R E. broker / R.E.
salesperson?
YES
NO
If (YES) please explain:
For Official Use Only
REGF-05 Rev.5/05
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
R E A L E S T A T E C O M M I S S I O N
Telephone: (860) 713-6150
APPLICATION FOR REIMBURSEMENT FROM THE
REAL ESTATE GUARANTY FUND
I
: In accordance with 20-324a-20-324j; Any person aggrieved by any action of a real estate broker, real
NSTRUCTIONS
estate salesperson or unlicensed employee of a broker by reason of the embezzlement of money or property or money
or property unlawfully obtained from any person by false pretenses, artifice, trickery or forgery or by reason of any
fraud, misrepresentation or deceit may recover damages upon approval.
Application for reimbursement from the guaranty fund must be submitted within two years of final determination or
expiration of time for appeal in connection with any judgment. The maximum amount paid to each consumer is
$25,000.
You must provide the following documentation to substantiate your claim:
1. Listing agreement or real estate contract agreement or contract used for judgment.
2. CERTIFIED copy of the court judgment;
3. Copies of Writ of execution (BOTH Bank and Property) including statement from officer executing same;
(not applicable to Small Claims Judgments) and;
4. If bankruptcy discharge, a certified copy of the Discharge of Debtor Notice including the schedule in which
you are listed as a creditor, and the amount of damages.
Return your completed application to:
Department of Consumer Protection, Real Estate Guaranty Fund, 165 Capitol Avenue, Hartford, CT 06106.
CONSUMER INFORMATION:
Name
Court Docket #:
Address (No. & Street, City, State, Zip Code)
Home Telephone Number (With Area Code)
Work Telephone Number (With Area Code)/Email Address
REAL ESTATE BROKER / REAL ESTATE SALESPERSON INFORMATION:
Name
License Number:
Business Name
Work Telephone Number
(With Area Code)
Address (No. & Street, City, State, Zip Code)/Email Address
Date Contract was signed:
/
/
(Attach copy of contract)
1. Is the consumer a spouse or personal representative of the judgment debtor / defendant a R E. broker / R.E.
salesperson?
YES
NO
If (YES) please explain:
Amount Awarded on Judgment:
$
Date of Judgment:
/
/
Amount Paid
$
on Judgment:
Balance Owed
$
on Judgment:
(This application MUST be received within two (2) years
from this date in order to be eligible to apply)
Is the judgment being appealed by the R.E. Broker/ R.E. Salesperson
YES
NO
(If you check “YES”,
you cannot apply to the fund at this time.)
I have directed a sheriff to execute on my judgment against the R.E. Broker / R.E. Salesperson. The sheriff has
provided me with a return showing no personal or real property could be found to satisfy the judgment or that
the amount found was insufficient to satisfy my judgment.
I have attached a writ of execution upon the judgment and ask the Real Estate Commission to accept such as
compliance with 20-324e (5) and 20-324e (6).
B A N K R U P T C Y
IF THE R.E BROKER / R.E. SALESPERSON HAS FILED BANKRUPTCY, YOU MAY APPLY TO THIS FUND
BY PROVIDING THE FOLLOWING DOCUMENTATION:
1.
This application
2.
A Certified Copy of the Discharge of Debtor’s Notice
3.
Bankruptcy Schedule in which you are listed as a creditor
4.
Affidavit listing damages
C E R T I F I C A T I O N
I,
, being duly sworn, depose and say that:
Consumer’s name
1. I CERTIFY, UNDER PENALTY OF LAW (SEC. 53A-157, CLASS A MISDEMEANOR), THAT ALL
INFORMATION IN THIS APPLICATION IS THE TRUTH TO THE BEST OF MY KNOWLEDGE.
2. I believe in the obligation of an oath.
3. I am at least eighteen (18) years of age.
4. This affidavit is based upon my personal knowledge.
I do herby subrogate any and all rights that I have with regard to any monies ordered paid by the
Department of Consumer Protection Real Estate Commission for this claim.
In the event that I receive monies from any other source for this claim, I agree to repay the Guaranty
Fund for any amount previously paid to me from the fund for this claim.
NOTARIZED STATEMENT
On ___________________________, 200 , before me personally appeared ______________________ of
_____________________, Connecticut, known to me and made oath to the truth of the matters contained herein.
Signed (Applicant) _____________________________
Subscribed and sworn to before me this _______ day of ________________________, 200
Signed: __________________________________________
Commission Expires: _____________
(Comm. of Superior Court/Notary Public)
Page of 2