SUPERIOR COURT—PROCEDURE IN CIVIL MATTERS
`
`Sec. 24-24
`
`.
`
`liquidated damages, which mayinclude interest
`and reasonable attorney's fees, if the defendant
`has notfiled an answer by the answer date and
`the judicial authority has not required that a hear-
`ing be held concerning any request by the defend-
`ant for more time to pay, the judicial authority may
`render judgment in favor of the plaintiff without
`requiring the presence ofthe plaintiff or represen-
`tative before the court, provided the plaintiff has
`complied with the provisions of this section and
`Section 24-8. Nothing contained in this section
`shall prevent the judicial authority from requiring
`the presence of
`the plaintiff or representative
`before the court prior to rendering any such default
`and judgmentifit appears to the judicial authority
`that additional information or evidenceis required -
`prior to the entry of judgment.
`(b) in order for the judicial authority to render
`any judgment pursuant to this section at the time -
`set for entering a judgment whether by default,
`stipulation or other method, the following affidavits
`must have beenfiled by the plaintiff:
`(1) An affidavit of debt signed by theplaintiff or
`poles: who is not the plaintiff's ST
`
`sworn. sabeieeR is
`‘small
`claims writand noiiceof suitsigned and
`1 shallbe considered an
`notthepla ee orn
`afc ales iSora osesofthis section only
`
`fpos
`s forth either the amount due or theprincipal
`ifitse
`owed as of the date of the writ and contains an
`itemization of interest, attorney's fees and other
`lawful charges. Anyplaintiff claiming interest shal
`separately state the Interest and shall specify the
`dates from which and to which interest is com-
`puted, the rate of interest, the mannerin whichit
`was calculated and the authority upon which the
`claim forinterest is based. In those matters involv-
`ing the collection of credit card and other debt
`owedtoafinancial institution and subject to fed-
`eral requirementsfor the charging off of accounts,
`the federally recognized charge-off balance may
`be treated as the “principal” for purposesofthis
`section and itemization regarding such debt
`is
`required only frarn the date of the charge-oif bai-
`ance. Nothing in this section shall prohibit a mag-
`istrate from requiring further documentation.
`(A)
`If the instrument on which the contract ts
`based is a negotiable instrument or assigned con-
`tract, the affidav:t shall state that the instrument
`or contract is now owned by the plaintiff and a
`copy of the executed instrument sha!! be attached
`to the affidavit.
`If the plaintiff is not the original
`party with whom the instrument or contract was
`made, te plaintiff shall either (i) attach all bills of
`sale back to the original creditor and swearte its
`purchaseof the debt from the last owner in its
`affidavit of aebt while also referencing the
`
`(P.B. 1978-1997, Sec. 575.)
`in Smaii Claims;
`Sec. 24-24.
`Judgments
`When Presence ofthe Plaintiff or Represen-
`tative is Not Required for Entry of Judgment
`(a) In any action based on an expressor impliéc
`promise to pay a definite sum and claiming only
`
`© Copyrighted by the Secretary of the State <f ‘he State of Connecticut
`
`
`
`
`This communication is from a de
`SMALL CLAIMS WRIT
`
`This form is available
`AND NOTICE OF SUIT
`JD-CV-40 Rav. 7-22
`in other language(s).
`.
`j
`j
`C.G.S. §§ 51-15, 51-345(g)
`This is an attempt to collect a debt and any information will be used for that purpose.
`1.) Address of Court
`2.) Case type code
`$10
`
`STATE OF CONNECTICUT
`SUPERIOR COURT
`ff
`SMALL CLAIMS SESSION \
`www.jud.ct.gov
`
`
`
`(Seelist on reverse page 1)
`
`4.) If "Yes" to question #3, the rental property is locatedin the following town:
`3.) Is this claim between a landlord and a tenant?
`
`(Selectone)
`[_] Yes
`[x] No
`
`
`
`Name (Last, First, Middle Initial) and Address of Each Party (Number; Street; P.O. Box; Town; State; Zip; Country, if not USA)
`
`
`
`
`Name: Endodontics, LLC
`
`
`(Select one)
`[x] LLC [[] Partnership
`
`§.) First
`
`Address: 60 Washington Avenue #202 | Hamden CT 06518
`[_] Individual
`["] DBA [] Corporation
`plaintiff
`
`Telephone: 203 281-6574
`
`
`Attorney's Juris Number|Telephone number(w/area code)
`6.) Name, address, and zip code of Attorneyfor plaintiff(s)
`414810
`203 777-9797
`Law Offices of Robert J. Romano
`
`
`PO Box 5204 | Greenwich CT 06831-0504
`Name: Jordan Island
`
`
`
`["] LLC [_] Partnership
`(Selectone)
`7.) First
`Address: 358 Washington Avenue | West Haven CT 06516-5327
`defendant
`
`["] DBA [_] Corporation
`Individual
`
`
`
`Telephone:
`E-mail:
`[_] For more than1plaintiff/defendant, attach Continuation of Parties (form JD-C\V-67) and select this box.
`
`
`
`8.) If this claim is a consumer debt, which is a debt or obligation made primarily for personal, family, or household reasons, explain why you
`believe the statute of limitations has not expired.
`Services rendered on 12/22/22. Balance represents defendant's responsibilty after insurance processing.
`
`9.) In the last 6 months, how did you verify that the address given for defendant(s) is accurate?
`Select all boxes that apply and provide the dates verified.
`| checked townor city records (for example, checking a streetlist or tax records) on: 02/23/24
`[_] | checked with the Department of Motor Vehicles on:
`(date)
`LC]
`| received correspondence(letters or other mail) from the defendant with that return address on:
`CJ | received other proof from the defendantthat the address is current(describe details below)
`
`(date)
`
`(date)
`
`At least 4 weeks before this action wasfiled, | sent a letter by first class mail to the defendant at the address used andit has not
`been returned to me by the United States Postal Service as of: 02/23/24
`(date)
`10.) Amountclaimed*
`Plus Costs | Plus pre-judgmentinterest**
`421.50
`[-] Plus double damagesfor security deposit withheld**
`*The Amount claimed cannot exceed $5,000 or $15,000 for a home improvement contract case (S20).
`“If you are claiming pre-judgmentinterest or double damagesfor security deposit withholding, select the box(es). Do not include these
`amounts in box 10.
`
`**You MUSTexplain how much you
`wanifor each item in section 17 below.
`
`To defendant(s):
`11.) You are being sued. The plaintiff(s) claims you owe this moneyfor the following reasons:
`Endodontic services provided to the defendantat the plaintiff's place of their doing business in HAMDEN, CT. This is an
`attempt to collect a debt and any information obtainedwill be used for that purpose. This communication is from a debt
`collector. Plaintiff requests post judgmentinterest to be granted according to C.G.S. 37-3. The defendantis actively
`employed.
`
`
`
`The person signing below, being duly sworn, states that he or she has read the claim above and the information contained in this form and,
`to the best of his or her knowledge,information and belief, there is good ground to support the claim and the informationis true.
`
`12.) Signed
`Type in nameof person signing al left and title,applicable]
`For Court Use Only (Date/Stamp)
`B. Cha, DMD
`
`
`Subscribed and
`
`
`
`sworn to before me on
`i
`
`}
`Z
`4A
`
`ADANOTICE @xf ives
`'O\
`3d eu
`The Judicial Branch of the State of Connecticut complies with the Americaiis with
`ADA,contacta court clerk or an ADA contactpersonlisted at www.jud.ct.gov/ADA. |Number
`Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the
`
`
`
`
`
`
`
`
`Endodontics. LLC
`
`. 60 Washinglon‘Ave, Suite 202
`Hamden, CT 06518-3026
`~
`|
`(203) 281-6674
`
`
`ACCOUNT:NAMEANDMAILING"ADDRESS |i
`
`
`
`
`JordanIsland
`i
`358 Washington Avenue
`'
`....West Haven,CT 06616,
`i
`
`
`
`
` 222
`Hipaa Redacted ©
`12/22/2022 Hipaa Redacted
`42/22/2022 Hipae Redacted
`12/22/2022. Patient-Gard Payment - Thank you
`
`,
`
`ORR.Caecheck#:grr7an00) 1~Thankyou
`
`02/16/2023 EOB/STATEMENT MAILED.
`02/16/2023 ContractDifferential
`
`Tew’
`|Ei‘agreethatI'amfinancial!wicks,
`icesrenderedbythedoctorregardlessof‘my.
`
`insurance coverage. Est
`ifyou'do not have dental insurance thenpayment
`
`
`infull is due at the ti
`rendered, unless other payment arrangements have
`
`all.insuranceane dusubjecttoa$10.00permonthlatefee.
`Iagreetopay
`been approvedin w
`ind
`‘
`ur staff. Lagree that all balances 30 days pastdue (after
`
`eeythat[havereadand.understandthisform.and.ifrequest,fwill Coens
`YE lia bylowandall costsofcollection in-case ofdefault on
`ee
`
`oxAantttosaveteeth.Ifthetoothtumsouttobenon-salvageableupon
`
`
`
`fee willbe charged accordingly instead ofthe fee listed above.
`
`
`
` COMMENT:
`
`
`
` JIN
`
`eee
`
`$0.00
`
`2260
`
`$0.00
`d
`
`JIANG
`NP! Submitted: 1578778243
`pine. JORDAN 99195032800;
`ri
`2
`119540140; 223263035800
`
`ADA CODE
`HIPAA REDACTED
`ADA CODE
`
`HIPAA REDACTED
`
`\2iaerea]
`
`01 32
`
`4 2122/22
`
`|
`
`$200.00}
`
`$200.00
`
`||.oa ! :
`
`[sieweolsiaer
`
`Nt q
`eo yY
`“
`. ingtipwer retreatment of a root canal.
`
`Notes:
`PSSThe chargeexceedstheallawablerate for thisservice,
`:
`BOI Your request has bean denied. Cone beam payania only faens ongame day as an
`
`This benefit refiects your agreementwith PPO - Maximumtare Dental Network O
`
`
`
` SyReeaeET
`
`Or. JIN JIANG DOS
`Dentist
`REDACTEDSLAND
`Name:
`EmployerREDACTED
`Grove:
`REDACTED
`Document: 230141866177
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`|
`|
`
`Claim detail
`
`;
`ISLAND, JORDAN
`Name/Relationship:JORDANISLAND/Depandent
`Claim:
`3011142478 99 035
`ID:
`HXXKXXKSAB
`i
`:
`Pationt
`You Negotlated
`Servicecoda,tooth#.
`Date of
`Owes
`Fae
`submited
`service
`description
`:
`$71.00
`x&
`$460.00
`$71.00
`122222 HIPAA REDACTED
`
`
`
`
`12/22/22 HIPAA REDACTED 50%__$84.90§94°00 appiiod to$20000 5459.00 $182.00 $95.60
`
`
`
`
`
`
`
`
`—_81-890.00. $1,041.00 $1,014.00 50% eeQe1222 oan REDACTED $505.60
` $1,241.00
`:
`$1,940.00
`O
`:
`!
`|
`we
`Ww WY
`s
`PLANdeductible
`R
`a)
`Additional Note(s):
`* The network savings were obtained through a ralatioa 5 s@SOENTEMAX vendor.
`* Negotiated ratas do not apply to non-covered servighé
`inStates that prohibit limitations for services not
`
`covered under a plan. Participating providers in
`s may charge their non-negotiated rate for non-
`6
`covered services. This amount may be higher
`unt identified under the Patient owes column and
`the patient is responsible for the amountoh
`on-covered service. Please discuss with your patient
`r
`
`the fees charged for services not coveredainder thir
`dentalpian.
`
`Allowed
`
`amount
`
`$1,170.00
`
`emaini
`
`Lf
`
`0.00
`
`MatLife
`
`Paid
`
` _
`
`
