Fill and Sign the Jd Fm 75 Sample Form

J. Other (Specify): Other (Specify): Type of Debt Motion to Open or Modify Civil Application for Custody and/or VisitationPaternity A. Real Estate.... B. Motor VehiclesC. Other Personal Property......... D. Savings Account Balance (Total of all accounts)....... E. Checking Account Balance (Total of all accounts)..... F. Cash .......................................................................... G. Other Assets (Specify):.............................................. Type of proceeding APPLICATION FOR WAIVER OF FEES/APPOINTMENT OF COUNSELFAMILY, CIVIL, HOUSING STATE OF CONNECTICUT SUPERIOR COURT JD-FM-75 Rev. 7-1 0 C.G.S. §§ 46b-231, 52-259b P.B. §§ 8-2, 25-63 Name of applicant (Last, first, middle initial) Docket number (If applicable) Address of applicant (Number, street, town, state and zip) Telephone (Area code first) Name of case Housing Session JudicialDistrict Address of court Appointment of Counsel Financial Affidavit Amount Owed Monthly Payment 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. 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 ask for a hearing on the application. To: The Superior Court Instructions to Clerk Instructions to person asking to have the fees waived or for appointment of anattorney (applicant) I ask that the court order that I do not have to pay fees or order the State to pay the fees below. ("X" all that apply) Entry fee State Marshal's fee Other (Specify): I ask that the court appoint an attorney to represent me. 1. Dependents 2. Monthly Income 3. Monthly Expenses Total Liabilities Page 1 of 2 5. Liabilities/Debts (for example, credit card balances, loans, etc. Do not include mortgage or loan balances that are listed under "Assets".) Total number of dependents (not including yourself) A. Gross monthly income (before deductions) ........................... B. Net monthly income after taxes from monthly employment.............C. Other income (for example, TANF, Social Security, etc.) (Specify source) .. Source: Total Monthly Income (B+C) Estimated Value Loan Balance Equity Real Estate Motor Vehicle Other Property Savings Checking Other Assets Total Assets 4. Assets Fee Waiver Contempt Dissolution of Marriage or Divorce Dissolution of Civil UnionHousing Filing fee Geographical AreaNumber (Applicable only in a contempt proceeding or to the putative father in a paternity proceeding.) (for example, jewelry, furniture, etc.) Cash 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 .................................... Total Monthly Expenses Not indigent hereby orders Entr y fee I certify that the information on page 1 is true and accurate to the best of my knowledge and that I can, if asked, document all income, expenses, and liabilities listed on 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 ofhis or her official function may be punishable by a fine and/or imprisonment. Signed (Applicant) The Court, having found the applicant the application: Notice Subscribed and sworn to before me: Signed (Notary Public, Commissioner of the Superior Court, Assistant Clerk) Order Granted as follows: Indigent and unable to pay 1. The following fees are waived 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, Assistant Clerk) Date signed JD-FM-75 (back) Rev. 7-1 0 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. Signed (Applicant) Date signed Order After Hearing Hearing to be held at the Court location shown on page 1 on the date and time shown below: Hearing on (Date) At (Time) Room number Signed (Assistant Clerk) Other (Specify:) Denied. By the Court (Print or type name of Judge/FSM) On (Date) Signed (Judge, FSM, Assistant Clerk) Date signed Not indigent hereby orders The Court, having found the applicant the application: Granted as follows: Indigent and unable to pay 1. The following fees are waived 2. The following fees are ordered paid by the State State Marshal's fee not to exceed $ Filing fee Entry fee Other (Specify:) Filing fee Print name of person signing at left Date signed On (Date) Page 2 of 2