Application For Waiver Of Fees Or Appointment Of Counsel

APPLICATION FOR WAIVER OF FEES/APPOINTMENT OF COUNSEL FAMILY STATE OF CONNECTICUT Instructions to person asking to have the fees waived or for appointment of an JD-FM-75 Rev. 7-11 attorney (applicant) C.G.S. §§ 46b-231, 52-259b 1. Print or type all information requested. P.B. §§ 8-2, 25-63 2. Sign the Financial Affidavit section in front of a court clerk, a notary public or an attorney. This form must be used only for family and family support magistrate matters. For civil, housing and 3. Bring this form to the superior court where your case will be filed or is pending. small claims matters, use form JD-CV-120. 4. If your application for fees payable to the court or for costs of service of process is denied, you To: The Superior Court may ask for a hearing on the application. SUPERIOR COURT www.jud.ct.gov Instructions to Clerk 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. Name of case Docket number (If applicable) Judicial District Address of court Name of applicant (Last, first, middle initial) Address of applicant (Number, street, town, state and zip) Type of proceeding Contempt Dissolution of Marriage (Divorce) Dissolution of Civil Union Motion to Open or Modify Application for Custody and/or Visitation Paternity Telephone (Area code first) Other (Specify): Fee Waiver 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) Entry fee (fee to file case) Costs of service of process (delivery of papers by state marshal or other proper officer) Filing fee (fee to file motion, etc.) Costs for participating in parenting education under C.G.S. § 46b-69b Other (For example costs of notice by publication or for a certified copy of judgment, etc.) (Specify): Appointment of Counsel (This applies only in a contempt proceeding or to the putative father in a paternity proceeding.) I ask that the court appoint an attorney to represent me. Financial Affidavit 1. Dependents 4. Assets Estimated Value Loan Balance Equity Total number of dependents (not including yourself) 2. Monthly Income 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): Real Estate A. Real Estate ........ Motor Vehicle B. Motor Vehicles.... C. Other Personal Property ............ Other Property Savings (for example, jewelry, furniture, etc.) D. Savings Account Balance (Total of all accounts) ....... Checking Total Monthly Income (B+C)* 3. Monthly Expenses E. Checking Account Balance (Total of all accounts) ...... A. Rent/Mortgage .............................. F. Cash................................................................. B. Real Estate Taxes.......................... C. Utilities (telephone, fuel heat, electric, water, gas, cable, etc.) ....................... G. Other Assets (Specify): D. Food (less SNAP (food stamps), if any) ... 5. Liabilities/Debts (for example, credit card balances, loans, etc. Do not E. Clothing ....................................... F. Insurance Premiums (medical/dental, auto, life, home) ............................... include mortgage or loan balances that are listed under "Assets".) Cash Other Assets Total Assets Type of Debt Amount Owed Monthly Payment G. Medical/Dental .............................. H. Transportation (bus, gasoline, etc.) ...... I. Child Care .................................... J. Other (medical, dental, child support paid, alimony paid, etc.) (Specify): Total Monthly Expenses* Total Liabilities * If you claim zero Total Monthly Income or Expenses, explain how you are supported: Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 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. Notice X 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. Print name of person signing at left Signed (Applicant) On (Date) Subscribed and sworn to before me: Date signed Signed (Notary Public, Commissioner of the Superior Court, Assistant Clerk) Order Not indigent Indigent and unable to pay The Court, having found the applicant ("X" all that apply): Indigent or unable to pay for parenting education program under C.G.S. § 46b-69b, hereby orders the application: Granted as follows: 1. The following costs are ordered paid by the State Costs of service of process not to exceed: $ Other (Specify): 2. The following fees are waived Entry fee Filing fee Other (Specify): 3. All costs for participation in a parenting education program shall be covered by the service provider pursuant to C.G.S. § 46b-69b, because the applicant is found indigent or unable to pay. 4. Counsel is Appointed (Name): Denied. If denied only in part, specify: Counsel is not appointed because the applicant does not face potential incarceration. By the Court (Print or type name of Judge/Fam. Sup. Magistrate) On (Date) Signed (Judge, FSM, Assistant Clerk) Date signed 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 applications for fee waiver for parenting education or to appointment of counsel. I request a court hearing on the application. X Date signed Signed (Applicant) 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) Order After Hearing The Court, having found the applicant Indigent and unable to pay Not indigent hereby orders the application: Granted as follows: 1. The following costs are ordered paid by the State Costs of service of process not to exceed $ Other (Specify): 2. The following fees are waived Entry fee Filing fee Other (Specify): Denied for the following reason(s): By the Court (Print or type name of Judge/FSM) JD-FM-75 (back) Rev. 7-11 On (Date) Page 2 of 2 Signed (Judge, FSM, Assistant Clerk) Date signed American LegalNet, Inc. www.FormsWorkFlow.com