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
APPOINTMENT OF COUNSEL
I request that the court appoint counsel to represent me.
CHILD PROTECTION
EMANCIPATION
YOUTH IN CRISIS
I request that the court waive or have the State pay the fees indicated below. ("X" all that apply)
ENTRY FEE OTHER (Specify): FILING FEE MARSHAL'S FEE
FEE WAIVER
FAMILY WITH SERVICE NEEDS
DELINQUENCY
FINANCIAL ASSISTANCE:
STATE/CITY SSI ONLY UNEMPLOYMENT COMPENSATION WORKER'S COMPENSATION
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.
ESTIMATED VALUE LOAN BALANCE EQUITY REAL ESTATE MOTOR VEHICLE OTHER PROPERTY SAVINGS
Total No. of Dependents (not including yourself).... 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
V. ASSETS - APPLICANT
A. Real Estate..... B. Motor Vehicles C. Other Personal Property..........
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
D. Savings Account Balance (Total of all accounts)........ E. Checking Account Balance (Total of all accounts)...... F. Other Assets (Specify):................................................ TOTAL ASSETS
MONTHLY PAYMENT
CHECKING OTHER ASSETS
V. LIABILITIES/DEBTS - APPLICANT
TYPE OF DEBT
(Do not include mortgage or loan balances that are listed under "Assets".)
AMOUNT OWED
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
X
SIGNED (Applicant)
PRINT NAME OF PERSON SIGNING AT LEFT ON (Date)
DATE SIGNED
SUBSCRIBED AND SWORN TO BEFORE ME:
SIGNED (Notary Public, Commissioner of the Superior Court, Assistant Clerk)
ORDER NOT INDIGENT hereby orders
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)
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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