Free AFFIDAVIT OF INDIGENCY -- FEE WAIVER, CRIMINAL - Connecticut

AFFIDAVIT OF INDIGENCY -- FEE WAIVER, CRIMINAL
JD-AP-48 Rev. 1-09 C.G.S. §§ 54-56g, 52-259b

STATE OF CONNECTICUT

SUPERIOR COURT
www.jud.ct.gov

Instructions to Applicant: Print or type all information and sign affidavit in front of court clerk, notary public or an attorney. Instructions to Clerk: If application is denied and a hearing is requested, schedule hearing and issue notice of hearing.
Name of Case Specify Fee to be Waived (Copies, transcript, program fee, etc ) Docket Number

Net Income

I. Income (Net income after taxes; include all sources)......................... Public Assistance Received: No Yes (If yes, specify type): II. Dependents (Total number of dependents)........................................ III. Assets
A. Real Estate......................... B. Motor Vehicles.................... C. Other personal property...... $ $ $
Estimated Value Mortgage Balance

$

Number of Dependents

Equity Real Estate

$ $ $

$
Motor Vehicle

$
Other

$
Savings

D. Savings accounts (Total of all accounts)................................................ E. Checking accounts (Total of all accounts).............................................. F. Stocks: Name G. Bonds: Name

$
Checking

$
Stock Value

$
Bond Value

$
Total Assets

IV. Liabilities
Date Source Amount of Debt

$
Balance Due Weekly Payment

$ $ $ $ $

$ $ $ $ $
Total Liability

$ $ $ $ $

V. Affidavit I certify that the information above is accurate to the best of my knowledge and that I can, if requested, submit documentation for all income, assets and liabilities listed above.

$

Notice:
(Attach Pertinent Records)
Signed (Applicant)

Any false statement you make 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

Subscribed and sworn to before me:

Signed (Notary public, commissioner of superior court, assistant clerk)

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Pursuant to General Statutes § 52-259b, for purposes of determining whether a party is indigent and unable to pay a fee to the court or to pay the cost of service: "There shall be a rebuttable presumption that a person is indigent and unable to pay a fee or fees or the cost of service of process if (1) such person receives public assistance or (2) such person's income after taxes, mandatory wage deductions and child care expenses is one hundred twenty-five per cent or less of the federal poverty level. For purposes of this subsection, "public assistance" includes, but is not limited to, state-administered general assistance, temporary family assistance, aid to the aged, blind and disabled, food stamps and Supplemental Security Income."

Order of Court
The Court, having found the applicant hereby orders the application: Granted as follows: 1. The following fees payable to the court are waived. (specify:) ___________________________________ 2. The following fees are ordered paid by the State: service of process not to exceed $________________ (specify amount if limited) other (specify:)___________________________________________________ Denied
By the Court (Print name of judge) On (Date) Signed (Judge, Assistant Clerk) Date Signed

Indigent and unable to pay

Not indigent

Request For Hearing On Fee Waiver Application (Only if initially denied without a hearing)
I request a court hearing on the application for a fee waiver.
Signed (Applicant) Superior Court Judicial District or Geographical Area Number Date of Hearing Date Signed Time of Hearing Signed (Assistant Clerk) Room Number

Hearing To Be Held At

Address of Court (Number, street and town)

Order Of Court After Hearing
The Court, having found the applicant hereby orders the application: Granted as follows: 1. The following fees payable to the court are waived. (specify:) ___________________________________ 2. The following fees are ordered paid by the State: service of process not to exceed $________________ (specify amount if limited) other (specify:)___________________________________________________ Denied
By the Court (Print name of judge) On (Date) Signed (Judge, Assistant Clerk) Date Signed

Indigent and unable to pay

Not indigent

JD-AP-48 (back/page 2) Rev. 1-09

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