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Connecticut Application for Waiver of Fees Form


Connecticut Application for Waiver of Fees Form
Connecticut Application for Waiver of Fees Form
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Clicking on the question marks ( ) will give you information about that section of the form.
Total Monthly Expenses*
J. Other
(medical, dental, child support paid,
alimony paid, etc.) (Specify):
1. Dependents (another person who is supported by you)
2. Monthly Income
3. Monthly Expenses
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, child support, alimony,
etc.) (Specify which one(s) here):
Total Monthly Income (B+C)*
A. Rent/Mortgage ..............................
B. Real Estate Taxes..........................
C. Utilities
(telephone, fuel heat, electric,
water, gas, cable, etc.) .......................
D. Food (less SNAP (food stamps), if any) ...
E. Clothing .......................................
F. Insurance Premiums (medical/dental,
auto, life, home) ...............................
G. Medical/Dental ..............................
H. Transportation (bus, gasoline, etc.) ......
I. Child Care ....................................
Type of Debt
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. Cash.................................................................
G. Other Assets (Specify):
Type of proceeding
("x" all that apply)
APPLICATION FOR WAIVER OF
FEES/APPOINTMENT OF COUNSEL
FAMILY
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
JD-FM-75 Rev. 10-13
C.G.S. §§ 46b-231, 52-259b
P.B. §§ 8-2, 25-63; P.A. 13-310
Judicial District
Appointment of Counsel (This applies only in a contempt proceeding or to the putative father in a paternity proceeding.)
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 an
attorney (applicant)
I ask that the court order that I do not have to pay fees or costs or order the State to pay the fees and costs below. ("X" all that apply)
Total Liabilities
5. Liabilities/Debts (for example, credit card balances, loans, etc. Do not
include mortgage or loan balances that are listed under "Assets".)
Estimated Value Loan Balance Equity
Total Assets
4. Assets
Fee Waiver
(for example, jewelry, furniture, etc.)
Name of case
Docket number (If applicable)
Address of court
Name of applicant (Last, first, middle initial) Address of applicant (Number, street, town, state and zip) Telephone (Area code first)
Contempt Motion to Open or Modify
Other (Specify):
Dissolution of Marriage (Divorce)
Dissolution of Civil Union
Application for Custody
Application or Petition for Visitation
Paternity
Entry fee (fee to file case)
Filing fee (fee to file motion, etc.)
Costs of service of process (delivery of papers by state marshal or other proper officer)
Other (For example costs of notice by publication or for a certified copy of judgment, etc.) (Specify):
I ask that the court appoint an attorney to represent me.
Real Estate
Motor Vehicle
Other Property
Savings
Checking
Cash
Other Assets
This form must be used only for family and family
support magistrate matters. For civil, housing and
small claims matters, use form JD-CV-120.
Costs for participating in parenting education under C.G.S. § 46b-69b
* If you claim zero Total Monthly Income or Expenses, explain how you are supported:
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Connecticut Application for Waiver of Fees Form
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