Fill and Sign the Connecticut Financial Affidavit Search Edit Fill Sign Fax Form

(Page 1 of 6) FINANCIAL AFFIDAVIT JD-FM-6-LONG Rev. 2-16 P.B. §§ 25-30, 25a-15 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov FINAFFL Court Use Only *FINAFFL* Instructions Use this long version if either your gross annual income is more than $75,000 (see Section I. Income) or your total net assets are more than $75,000 (see Section IV. Assets), or if both are more than $75,000. Otherwise, use the short version, form JD-FM-6-SHORT. Docket number - FA - - S - ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. For the Judicial District of At (Address of Court) Name of case Name of affiant (Person submitting this form) Plaintiff Defendant Certification I understand that the information stated on this Financial Statement and the attached Schedules, if any, is complete, true, and accurate. I understand that willful misrepresentation of any of the information provided will subject me to sanctions and may result in criminal charges being filed against me. I. Income 1) Gross Weekly Income/Monies and Benefits From All Sources Computed based on year-to-date, but no less than the last 13 weeks. If computation is based on less than 13 weeks or if your computations are not reflective of current wages, explain: Paid: Weekly Bi-weekly Monthly Semi-monthly Annually If income is not paid weekly, adjust the rate of pay to weekly as follows: Bi-weekly → divide by 2 Semi-monthly → multiply by 2, multiply by 12, divide by 52 Monthly → multiply by 12, divide by 52 Annually → divide by 52 (a) Employer(s) Address(es) Base Pay: Job 1 $ Salary Wages Job 2 $ Salary Wages Job 3 $ Salary Wages Total of base pay from salary and wages of all jobs ............................................................................ $ (b) Overtime .............................................. $ (c) Self-employment ................................... $ (d) Tips................................................. ..... $ (e) Commissions ........................................ $ (f) Bonuses ............................................... $ (g) Dividends ............................................. $ (h) Interest ................................................. $ (i) Trusts................................................. .. $ (j) Annuities .............................................. $ (k) Pensions .............................................. $ ( l) Retirement/Tax Deferred Funds ............. $ (m) Social Security ...................................... $ (n) Disability............................................... $ (o) Unemployment ...................................... $ (p) Worker's compensation.......................... $ (q) Public Assistance (Welfare, TFA payments) ............................................. $ (r) Child Support (Actually received) ............ $ (s) Alimony (Actually received) .................... $ (t) Rental and income producing property .... $ (u) Royalties and other rights....................... $ (v) Contributions from household member(s) $ (w) Cash income ......................................... $ (x) Veterans Benefits .................................. $ (y) Other: $ (z) Total Gross Weekly Income/Monies and Benefits From All Sources (Add items a through y) $ Reset Form Print Form (Page 2 of 6) JD-FM-6-LONG Rev. 2-16 Hours worked per week Gross yearly income from prior tax year. Provide amount of income, not copies of forms ............................... $ List here and explain any other income including but not limited to: non-reported income; and support provided by relatives, friends, and others: 2) Mandatory Deductions (If consistent deductions don't occur every pay check provide average amounts.) (1) Federal income tax deductions Job 1 $ $ $ $ $ $ $ $Job 2 $ $ $ $ $ $ $ $Job 3 $ $ $ $ $ $ $ $ $ Totals (claiming exemptions) $ $ $ $ (2) Social Security or Mandatory Retirement (3) State income tax deductions $ (claiming exemptions) (4) Medicare (5) Health insurance (6) Union dues (7) Prior court order — child support or alimony (8) Total Mandatory Deductions (add items 1 through 7) $ $ 3) Net Weekly Income ................................................... ........................................................................... $ Subtract the Total Mandatory Deductions [see item I., 2), (8)] from the Total Gross Weekly Income/Monies and Benefits From All Sources [see item I., 1), z) ] 4) Other Deductions (1) Credit Union Loan .................................. $ (2) Savings ................................................. $ (3) Retirement............................................. $ (4) Subsequent Other Order of Court............ $ (i.e., child support, alimony) (5) Health Savings Account(s) or Plan(s)...... $ (6) Deferred Compensation or 401K ............ $ (7) Other Pre-Tax Deductions...................... $ (8) Other Wage Executions ......................... $ (9) Total Other Deductions (add items 1 through 8) .................................................. ............................. $ II. Weekly Expenses Not Deducted From Pay If expenses are not paid weekly, adjust the rate of payment to weekly as follows: Bi-weekly → divide by 2 Semi-monthly → multiply by 2, multiply by 12, divide by 52 Monthly → multiply by 12, divide by 52 Annually → divide by 52 Insert an ("x") in the box if you are not currently paying the expense, or if someone else is paying the expense. Home: Rent or Mortgage (Principal, Interest — Real Estate Taxes and Insurance if escrowed) $ 2nd Mortgage/Home Equity Line of Credit or Other Lien $ Property taxes and assessments .......... $ Household Improvements Condominium Fees................................ $ (Specify) $ Utilities: Oil .................................................. ...... $ Electricity .............................................. $ Gas .................................................. .... $ Water and Sewer ................................... $ Telephone/Cell/Internet............................ $ Trash Collection ...................................... $ T.V./Internet ............................................ $ Groceries (after food stamps): Including household supplies, formula, diapers ......................................... (Not including take out meals) $ Restaurants (Including take out meals) .................................................. ................................................ $ Transportation: Gas/Oil ................................................. $ Repairs/Maintenance ............................. $ Automobile Insurance/Tax/Registration ... $ Auto Loan or Lease ................................. $ Public Transportation ............................... $ Insurance Premiums: Medical/Dental (Out-of-pocket expense after Health Savings Account/Plan) ...... $ Life .................................................. ....... $ Uninsured Medical/Dental not paid by insurance .................................................. ................................. $ Reset Form Print Form (Page 3 of 6) JD-FM-6-LONG Rev. 2-16 Insert an ("x") in the box if you are not currently paying the expense, or if someone else is paying the expense. Personal Care (e.g., haircuts, etc.) ........... $ Clothing ................................................. . $ Dry Cleaning............................................ $ Entertainment.......................................... $ Alcohol, Smoking Products ....................... $ Vacation ................................................. $ Child(ren): Child Support of this case ................... $ Child Care Expense (after deductions, credits and subsidies) .......................... $ Child Support of other children other than this case (attach a copy of the order) ... $ Child(ren)'s Education (elementary, secondary, college, occupational) .......... $ Child(ren)'s activities (e.g., lessons, sports, etc.) .................................................. ... $ Child(ren)'s camp .................................... $ Child(ren)'s clothing and footwear ............. $ Check here if any part is court ordered Education (self)................................................... ................................................................................... $ Alimony: Payable to this spouse .................................................. ........................................................... $ Alimony: Payable to another spouse.................................................. ..................................................... $ Employment related expenses (which are not reimbursed): Uniforms .................................................. ........................................................................................... $ Travel .................................................. ............................................................................................... $ Required continuing education .................................................. ........................................................... $ Other (Specify): $ Charitable Contributions .................................................. ....................................................................... $ Child(ren)'s allowance .................................................. .......................................................................... $ Extraordinary travel expenses for visitation with child(ren) .................................................. ...................... $ Other (Specify): $ Total Weekly Expenses Not Deducted From Pay ................................................................................... $ III. Liabilities (Debts) Do not include expenses listed above. Do not include mortgage current principal balance or loan balances that are listed under “Assets.” Creditor Name/Type of Debt Balance Due Date Debt Incurred/ Revolving Weekly Payment Credit Card Debt Sole Joint $ $ Sole Joint $ $ Sole Joint $ $ Sole Joint $ $ Sole Joint $ $ Other Consumer Debt Sole Joint $ $ Sole Joint $ $ Tax Debt Sole Joint $ $ Sole Joint $ $ Health Care Debt Sole Joint $ $ Sole Joint $ $ Other Debt Sole Joint $ $ Sole Joint $ $ Sole Joint $ $ Sole Joint $ $ Sole Joint $ $ Sole Joint $ $ Sole Joint $ $ (A). Total Liabilities (Total Balance Due on Debts) ................................... $ (B). Total Weekly Liabilities Expense ................................................................................................... $ Reset Form Print Form (Page 4 of 6) JD-FM-6-LONG Rev. 2-16 IV. Assets Note: Under "Ownership" indicate S for sole, JTS for joint with spouse, and JTO for joint with other. You must complete the last column to the right "Value of Your Interest" in each applicable section. A. Real Estate (including time share) Address Ownership S JTS JTO a. Fair Market Value (Estimate) b. Mortgage Current Principal Balance c. Equity Line of Credit and Other Liens d. Equity (d = a minus (b + c)) e. Value of Your Interest Home $ $ $ $ $ Other $ $ $ $ $ $ $ $ $ $ Total Net Value of Real Estate:  $ B. Motor Vehicles Year Make Model JTO JTS S Ownership a. Value b. Loan Balance c. Equity (c = a minus b) d. Value of Your Interest 1: $ $ $ $ 2: $ $ $ $ 3: $ $ $ $ Total Net Value of Motor Vehicles:  $ C. Bank Accounts Do not include custodial accounts or child(ren)'s assets — complete Section V. below. Institution Account Number (last 4 numbers only) Ownership S JTS JTO Current Balance/ Value Value of Your Interest Checking $ $ $ $ $ $ Savings $ $ $ $ Certificate of Deposit $ $ Credit Union $ $ Other Account (i.e., money market, U.S. Savings Bonds, etc.) $ $ Total Net Value of Bank Accounts:  $ D. Stocks, Bonds, Mutual Funds, Bond Funds Company Account Number (last 4 numbers only) Listed Beneficiary Current Balance/ Value Stocks $ Bonds $ Mutual Funds $ Bond Funds $ Total Net Value of Stocks, Bonds, Mutual Funds, Bond Funds:  $ E. Insurance (exclude children) D = Disability L = Life Name of Insured D L Company Account Number (last 4 numbers only) Listed Beneficiary Current Balance/ Value $ $ $ Total Net Value of Insurance:  $ Reset Form Print Form (Page 5 of 6) JD-FM-6-LONG Rev. 2-16 Current Balance/ Value F. Retirement Plans (Pensions on Interest, Individual IRA, 401K, Keogh, etc.) Type of Plan Name of Plan/Bank/Company Account Number (last 4 numbers only) Listed Beneficiary Receiving Payments Yes No $ Yes No $ Yes No $ Yes No $ Yes No $ Total Net Value of Retirement Plans:  $ G. Business Interest/Self-Employment If you own an interest in a business, or are self-employed, complete this section. Name of Business Percent Owned Value % $ % $ Total Net Value of Business Interest/Self-Employment:  $ H. Institutional Held Assets Institution/Individual Account Number (last 4 numbers only) Listed Beneficiary Current Balance/ Value Annuity $ Cash in Brokerage $ Account(s) $ Funds Held in Escrow Including Money Held by Attorney $ Profit Sharing $ Total Net Value of Institutional Held Assets:  $ I. Other Assets Name of Asset Current Balance/ Value Name of Asset Current Balance/ Value Arts and Antiques $ Cash on hand $ Collections $ Contents of Safe or Safe Deposit Box $ Crops/Livestock $ Firearms $ Home Furnishings $ Jewelry $ Money Owed to You $ Tools/Equipment $ Name of Asset Name of Beneficiary Current Balance/ Value Inheritances $ Other (specify) $ $ Total Net Value of Other Assets:  $ J. Total Net Value All Assets (add items A through I) .................................................. ............................. $ V. Child(ren)'s Assets Include Uniform Gift to Minor Account, Uniform Trust to Minor Account, College Accounts/529 Account, Custodial Account, etc. Institution Account Number (last 4 numbers only) Listed Beneficiary Person Who Controls the Account (Fiduciary) Current Balance/Value $ $ $ $ $ Total Net Value of Child(ren)'s Assets:  $ Reset Form Print Form (Page 6 of 6) JD-FM-6-LONG Rev. 2-16 VI. Health Insurance (Medical and/or Dental Insurance) Company Name of Insured Person(s) Covered by the Policy Do you or any member of your family have HUSKY Health Insurance Coverage? If Yes, whom? Yes No I Don't Know Important: If you have other financial information that has not yet been disclosed, you have an affirmative duty to disclose that information. List additional information below: Summary (Use the amounts shown in Sections I. through IV.) Total Net Weekly Income (See Section I. 3) .................................................. ............................................. $ Total Weekly Expenses and Liabilities (Total From Section II. + III.(B)) .................................................. .... $ Total Cash Value of Assets (See Section IV. J.) .................................................. ...................................... $ Total Liabilities (Total Balance Due on Debts) (See Section III. (A)) .................................................. ........... $ Certification I certify under the penalties of perjury that the information stated on this Financial Statement and the attached Schedules, if any, is complete, true, and accurate. I understand that willful misrepresentation of any of the information provided will subject me to sanctions and may result in criminal charges being filed against me. I, the Plaintiff Defendant herein, residing at , telephone number , being duly sworn, depose and say that the following is an accurate statement of my income from all sources, my liabilities, my assets and my net worth, from whatever sources, and whatever kind and nature, and wherever situated. Signed (Affiant) Date signed Signed (Notary, Commissioner of Superior Court, Assistant Clerk, Other Proper Officer under Sec. 1-24 of the Connecticut General Statutes) Print name and title of person signing at left Date signed Reset Form Print Form