Conn. Practice Book Form 217

The undersigned, on behalf of the _________________________, hereby propounds the following

interrogatories to be answered under oath by the party being served within sixty (60) days of the service

hereof in compliance with Practice Book Section 13-2.

Definition: ‘‘Y ou’’ shall mean the party to whom these interrogatories are directed except that if suit

has been instituted by the representative of the estate of a decedent, ward, or incapable person, ‘‘Y ou’’

shall also refer to the party’s decedent, ward or incapable person unless the context of an interrogatory

clearly indicates otherwise.

In answering these interrogatories, Y ou are required to provide all information within your knowledge,

possession or power. If an interrogatory has subparts, answer each subpart separately and in full and

do not limit the answer to the interrogatory as a whole. If any interrogatories cannot be answered in

full, answer to the extent possible.

(1) State the following:

(a) your full name;

(b) any other name(s) by which Y ou have been known;

(c) your date of birth;

(d) your home address;

(e) your business address.

(2) State whether Y ou have ever been enrolled in a plan offered pursuant to any Medicare Part

If your answer to Interrogatory #2 is affirmative, state the following:

(a) the effective date(s);

(b) your Medicare claim number(s);

(c) your name exactly as it appears on your Medicare card.

(3) State whether a plan offered pursuant to any Medicare Part has paid any bills for treatment of any

injuries allegedly sustained as a result of the incident alleged in your complaint.

If your answer to Interrogatory #3 is affirmative, state the amount paid.

(4) If Y ou are not presently enrolled in any Medicare Part, state whether Y ou are eligible to enroll.

(5) If Y ou are not presently enrolled in any Medicare Part, state whether Y ou plan to apply within the

next thirty-six (36) months.

Medicare Enrollment, Eligibility and Payments

No. CV- : SUPERIOR COURT

(Plaintiff): JUDICIAL DISTRICT OF

VS. : AT

(Defendant): (Date)

BY___________________________

I, _______________________, hereby certify that I have reviewed the above interrogatories and

responses thereto and that they are true and accurate to the best of my knowledge and belief.

Subscribed and sworn to before me this ____________day of _____________, 20 ____.

_____________________________

Notary Public/

Commissioner of the Superior Court

CERTIFICATION

I certify that a copy of this document was or will immediately be mailed or delivered electronically or

non-electronically on (date) _______ to all attorneys and self-represented parties of record and that

written consent for electronic delivery was received from all attorneys exempt from e-filing and self-represented parties of record who received or will immediately be receiving electronic delivery.

Name and address of each party and attorney that copy was or will immediately be mailed or

delivered to*

*If necessary, attach additional sheet or sheets with the name and address which the copy was or

will immediately be mailed or delivered to.

_________________________________________________________________________________

Signed (Signature of filer ) Print or type name of person signing Date Signed

_________________________________________________________________________________

Mailing address (Number, street, town, state and zip code) or Email address, if applicable Telephone number

HISTORY—2026: In the first sentence of the certification, “exempt from e-filing” was added after “from all attorneys.”

COMMENTARY—2026: The changes to this form are consistent with the changes to the proof of service language in Sec -

tion 10-14 (a).

TECHNICAL CHANGE: The certification was updated to correct an error in the language and for consistency purposes.