Free JD-JM-114 - Connecticut


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Date: January 28, 2009
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State: Connecticut
Category: Court Forms - State
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APPLICATION FOR APPOINTMENT OF COUNSEL/WAIVER OF FEES
JD-JM-114 Rev. 2-2002 C.G.S. § 46b-135, 136, 53a-157b, § 52-259b, P.B. §§ 34-1, 8-2

INSTRUCTIONS TO APPLICANT
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.

INSTRUCTIONS TO CLERK

STATE OF CONNECTICUT

TO: THE SUPERIOR COURT
NAME OF APPLICANT (Last, first, middle initial) NAME OF EMPLOYER RELATIONSHIP TO CHILD

1. Bring completed form to a judge. 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.

SUPERIOR COURT
JUVENILE MATTERS www.jud.ct.gov

DATE OF BIRTH

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

ADDRESS OF EMPLOYER (No., street, town, state and zip)

MOTHER
NAME OF CHILD

FATHER

LEGAL GUARDIAN

OTHER
DATE OF BIRTH

DOCKET NO. (If applicable) TYPE OF PROCEEDING

ADDRESS OF COURT

CHILD PROTECTION

EMANCIPATION

APPOINTMENT OF COUNSEL
I request that the court appoint counsel to represent me.

YOUTH IN CRISIS

FAMILY WITH SERVICE NEEDS

DELINQUENCY

FEE WAIVER
FILING FEE MARSHAL'S FEE

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

FINANCIAL ASSISTANCE:
STATE/CITY SSI ONLY UNEMPLOYMENT COMPENSATION WORKER'S COMPENSATION Total No. of Dependents (not including yourself)....

FINANCIAL AFFIDAVIT IV. MONTHLY INCOME - OTHER PARENT
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) Please attach copy of recent paystub if available.

I. DEPENDENTS

II. MONTHLY INCOME - APPLICANT
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) Please attach copy of recent paystub if available.

V. ASSETS - APPLICANT
ESTIMATED VALUE LOAN BALANCE EQUITY REAL ESTATE MOTOR VEHICLE OTHER PROPERTY SAVINGS

A. Real Estate..... B. Motor Vehicles C. Other Personal Property.......... D. Savings Account Balance (Total of all accounts)........ E. Checking Account Balance (Total of all accounts)...... F. Other Assets (Specify):................................................ TOTAL ASSETS

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

CHECKING OTHER ASSETS

V. LIABILITIES/DEBTS - APPLICANT
TYPE OF DEBT

(Do not include mortgage or loan balances that are listed under "Assets".)
AMOUNT OWED
MONTHLY PAYMENT

Page 1 of 2

TOTAL LIABILITIES

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I certify that the foregoing information is 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.

NOTICE

SIGNED (Applicant)

PRINT NAME OF PERSON SIGNING AT LEFT ON (Date)

DATE SIGNED

X

SUBSCRIBED AND SWORN TO BEFORE ME:

SIGNED (Notary Public, Commissioner of the Superior Court, Assistant Clerk)

ORDER The Court, having found the applicant INDIGENT AND UNABLE TO PAY the application: GRANTED as follows: 1. Counsel is NOT APPOINTED APPOINTED 2. The following fees are waived ENTRY FEE FILING FEE (including additional $5.00, if required) NOT INDIGENT hereby orders

OTHER (Specify:)

3. The following fees are ordered paid by the State OTHER (Specify:) DENIED.
BY THE COURT (Print or type name of Judge) ON (Date)

MARSHAL'S FEE NOT TO EXCEED $

SIGNED (Judge, Ass't Clerk)

DATE SIGNED

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 appointment of counsel. REQUEST FOR HEARING ON DENIED APPLICATION 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)

ORDER AFTER HEARING The Court, having found the applicant the application: GRANTED as follows: 1. The following fees are waived ENTRY FEE FILING FEE (including additional $5.00, if required) OTHER (Specify:) INDIGENT AND UNABLE TO PAY NOT INDIGENT hereby orders

2. The following fees are ordered paid by the State OTHER (Specify:) DENIED.
BY THE COURT (Print or type name of Judge) JD-JM-114 (back/page 2 of 2) Rev. 2-2002 ON (Date)

MARSHAL'S FEE NOT TO EXCEED $

SIGNED (Judge, Ass't Clerk)

DATE SIGNED

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