Page 1 of 3Entry fee J. Other (Specify):1. Dependents2. Monthly Income3. Monthly ExpensesTotal number of dependents (Do not count yourself)A. Gross monthly income from all sources (Money you get in one month from work and other sources, before taxes) B. Net monthly income (after taxes) from employment C. Income from sources other than employment (For example, TFA, Social240Security, etc.) Total Monthly Income (B+C) =A. Rent/Mortgage B. Real Estate Taxes C. Utilities (Telephone, heat, electric,240water,240gas, 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 = List sources of other income:+ =Other (Specify): Type of DebtA. 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/PAYMENT OF COSTS - CIVIL, HOUSING, SMALL CLAIMS, AND APPELLATE JD-CV-120 Rev. 1-19 C.G.S. 247247 52-259, 52-259b, 52-259c P.B. 247247 8-2, 63-6STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.govHousing SessionJudicial DistrictFinancial Affidavit Amount Owed Monthly PaymentTo: The Superior CourtInstructions to person asking for the waiver (applicant) 1. Fill out Application. For help, see Help Text for Application for Waiver of Fees/Payment of Costs - Civil, Housing, Small Claims, and Appellate (form JD-CV-120H). 2. Sign the form under oath in front of a clerk, a notary, or an attorney. 3. Bring this form to the court where your case will be filed or is/was pending. 4. If this application for fees payable to the court or for costs of service of process is denied, you may ask for a hearing in the Request for Hearing on Denied Application section on page 2.I ask that the court order that I do not have to pay fees or to order the State to pay the costs below. (Check all that apply)Costs of service of process (Delivery of papers)Other fee (Specify):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 (Current worth) Loan Balance (Amount owed) Equity (Estimated Value minus Loan Balance) Total Assets = 4. AssetsFee Waiver/Payment of costsFiling fee(For example, jewelry, furniture, etc.) Name of case (Plaintiff v. Defendant) 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) Civil caseHousing (Landlord-Tenant case) Small claims case Real Estate Motor Vehicle Other Property Savings Checking Cash Other Assets Application Note: This form will be put in the case file, which may be available to be viewed by the public. Appellate matter (Supreme or Appellate Court) Appellate filing fee (Supreme or Appellate Court)Cost of the transcript for appealGrounds for Appeal (Complete if requesting waiver of Appellate filing fee (Supreme or Appellate Court) and/or payment of cost of the transcript for appeal.)The grounds on which I propose to appeal are: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3JD-CV-120 Rev. 1-19I certify that the information on this application is true and accurate to the best of my knowledge and that I can, if asked, document all income, expenses, and liabilities listed on this application. Signed (Applicant)2. The applicant is indigent and unable to pay the cost of service. A state marshal's fee not to exceed $ shall240be240paid by the state. 3. The applicant is indigent and unable to pay the cost of the transcript for appeal, which shall be paid by the State in accordance with Practice Book Section 63-6. 4. The applicant is indigent but able to pay fees, costs of service, and the cost of the transcript for appeal, and the application is denied. 5. The applicant is not indigent and the application is denied. 6. Denied: the applicant has repeatedly filed actions with respect to the same or similar matters, such filings establish an extended pattern of frivolous filings that have been without merit, the application sought is in connection with an action before the court that is consistent with the applicant's previous pattern of frivolous filings, and the granting of such application would constitute a flagrant misuse of Judicial Branch resources. 7. Denied. Other (Specify): 1. The applicant is indigent and unable to pay the following fees which are waived:- Notice - 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. Subscribed and sworn to before me: Signed (Notary Public, Commissioner of the Superior Court, Assistant Clerk)Order Filing fee By the Court (Print or type name of Judge) On (Date) Signed (Judge, Clerk) Date signed Print name of person signing at left Date signed On (Date)Having reviewed the application, the court finds as follows:Entry fee Other fee (Specify)Appellate filing fee (Supreme or Appellate Court) Docket number (If applicable) Name of case (Plaintiff v. Defendant) Request For Hearing On Denied Application (Fees payable to the court or costs of service of process)This section should be filled out only if the court has checked #4, 5, 6 or 7 above and denied the application. I request a court hearing on my application. Signed (Applicant) Date signedHearing Hearing to be held on (Date) At (Time) Location Signed (Clerk)u6. If you claim zero Total Monthly Income in number 2 above or zero Total Monthly Expenses in number 3 above, explain how you are supported: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3JD-CV-120 Rev. 1-19Order After Hearing By the Court (Print or type name of Judge) On (Date) Signed (Judge, Clerk) Date signed2. The applicant is indigent and unable to pay the cost of service. A state marshal's fee not to exceed $ shall240be240paid by the state. 3. The applicant is indigent and unable to pay the cost of the transcript for appeal, which shall be paid by the State in accordance with Practice Book Section 63-6. 4. The applicant is indigent but able to pay fees, costs of service, and the cost of the transcript for appeal, and the application is denied. 5. The applicant is not indigent and the application is denied. 6. Denied: the applicant has repeatedly filed actions with respect to the same or similar matters, such filings establish an extended pattern of frivolous filings that have been without merit, the application sought is in connection with an action before the court that is consistent with the applicant's previous pattern of frivolous filings, and the granting of such application would constitute a flagrant misuse of Judicial Branch resources. 7. Denied. Other (Specify): Having reviewed the application, the court finds as follows: Docket number (If applicable) Name of case (Plaintiff v. Defendant) 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.1. The applicant is indigent and unable to pay the following fees which are waived: Filing fee Entry fee Other fee (Specify)Appellate filing fee (Supreme or Appellate Court) American LegalNet, Inc. www.FormsWorkFlow.com