Free JD-FM-75 - Connecticut

APPLICATION FOR WAIVER OF FEES/APPOINTMENT OF COUNSEL FAMILY, CIVIL, HOUSING
JD-FM-75 Rev. 9-06 C.G.S. §§ 46b-231, 52-259b P.B. §§ 8-2, 25-63

STATE OF CONNECTICUT
INSTRUCTIONS TO APPLICANT INSTRUCTIONS TO CLERK 1. Bring completed form to a judge or, if applicable, to a family support magistrate. 2. If the application is granted, notify the applicant and counsel, if appointed. 3. If the application for fees payable to the court or for costs of service of process is denied, and upon the request of the applicant, schedule a hearing on the application. DOCKET NO. (If applicable) ADDRESS OF COURT

SUPERIOR COURT
www.jud.ct.gov

TO: THE SUPERIOR COURT
NAME OF CASE

1. Print or type all information requested. 2. Sign the Financial Affidavit section in front of a court clerk, a notary public or an attorney. 3. Bring this form to the superior court where your case will be filed or is pending. 4. If your application for fees payable to the court or for costs of service of process is denied, you may request a hearing on the application.

Judicial District

Housing Session

G.A. No.
ADDRESS OF APPLICANT (No., street, town, state and zip) TELEPHONE (Area code first)

NAME OF APPLICANT (Last, first, middle initial) TYPE OF PROCEEDING

CONTEMPT DISSOLUTION OF MARRIAGE/DIVORCE DISSOLUTION OF CIVIL UNION HOUSING

MOTION TO OPEN OR MODIFY CIVIL APPL. FOR CUSTODY AND/OR VISITATION PATERNITY

OTHER (Specify):

FEE WAIVER
I request that the court waive or have the State pay the fees indicated below. ("X" all that apply)
ENTRY FEE FILING FEE STATE MARSHAL'S FEE OTHER (Specify):

APPOINTMENT OF COUNSEL
(Applicable only in a contempt proceeding or to the putative father in a paternity proceeding.)

I request that the court appoint counsel to represent me.

FINANCIAL AFFIDAVIT I. DEPENDENTS
Total No. of Dependents (not including yourself)

IV. ASSETS
ESTIMATED VALUE LOAN BALANCE EQUITY REAL ESTATE MOTOR VEHICLE OTHER PROPERTY SAVINGS CHECKING

II. MONTHLY INCOME
A. Gross monthly income (before deductions)....................... B. Net monthly income after taxes from monthly employment............. C. Other income (i.e., TANF, Social Security, etc.) (Specify source)..... Source: TOTAL MONTHLY INCOME (B+C)

A. Real Estate.... B. Motor Vehicles C. Other Personal Property.........
(e.g., jewelry, furniture, etc.)

D. Savings Account Balance (Total of all accounts)....... E. Checking Account Balance (Total of all accounts).....
CASH

F. Cash ..........................................................................

III. MONTHLY EXPENSES
G. Other Assets (Specify):.............................................. A. Rent/Mortgage .............................. B. Real Estate Taxes ........................ C. Utilities (Telephone, heat, electric, water, gas, etc.) ................... D. Food ............................................. E. Clothing ........................................ F. Insurance Premiums (Medical/Dental, Auto, Life, Home) ..... G. Medical/Dental ............................. H. Transportation (bus, gasoline, etc.) I. Child Care .................................... J. Other
(Specify):

OTHER ASSETS

TOTAL ASSETS

V. LIABILITIES/DEBTS (e.g., credit card balances, loans, etc. Do not
include mortgage or loan balances that are listed under "Assets".)
TYPE OF DEBT AMOUNT OWED MONTHLY PAYMENT

TOTAL MONTHLY EXPENSES
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TOTAL LIABILITIES

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I certify that the foregoing information is true and accurate to the best of my knowledge and that I can, if requested, document all income, expenses, and liabilities listed on the front/page 1. Any false statement made by you under oath which you do not believe to be true and which is intended to mislead a public servant in the performance of his or her official function may be punishable by a fine and/or imprisonment.
PRINT NAME OF PERSON SIGNING AT LEFT ON (Date) DATE SIGNED

NOTICE

SIGNED (Applicant)

X
SUBSCRIBED AND SWORN TO BEFORE ME:
SIGNED (Notary Public, Commissioner of the Superior Court, Assistant Clerk)

ORDER The Court, having found the applicant the application: GRANTED as follows: 1. The following fees are waived INDIGENT AND UNABLE TO PAY NOT INDIGENT hereby orders

ENTRY FEE

FILING FEE

OTHER (Specify:) 2. The following fees are ordered paid by the State STATE MARSHAL'S FEE NOT TO EXCEED $ OTHER (Specify:) 3. Counsel is NOT APPOINTED APPOINTED (Name):

DENIED because the applicant does not face potential incarceration. DENIED.
BY THE COURT (Print or type name of Judge/Fam. Sup. Magistrate) ON (Date) SIGNED (Judge, FSM, Ass't Clerk) DATE SIGNED

REQUEST FOR HEARING ON DENIED APPLICATION The following section applies only to a denial of the application for waiver of fees payable to the court or for the costs of service of process. It does not apply to parenting education or to appointment of counsel. I request a court hearing on the application.

X
SIGNED (Applicant) DATE SIGNED

HEARING TO BE HELD AT THE COURT LOCATION SHOWN ON FRONT/PAGE 1 ON THE DATE AND TIME SHOWN BELOW:
HEARING ON (Date) AT (Time) ROOM NO. SIGNED (Assistant Clerk)

The Court, having found the applicant the application: GRANTED as follows: 1. The following fees are waived

ORDER AFTER HEARING INDIGENT AND UNABLE TO PAY

NOT INDIGENT

hereby orders

ENTRY FEE OTHER (Specify:)

FILING FEE

2. The following fees are ordered paid by the State STATE MARSHAL'S FEE NOT TO EXCEED $ OTHER (Specify:) DENIED.
BY THE COURT (Print or type name of Judge/FSM) ON (Date) SIGNED (Judge, FSM, Ass't Clerk) DATE SIGNED

JD-FM-75 (back/page 2 of 2) Rev. 9-06

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