Page 1 of 2To Applicant: Fill out this form and make 2 copies. File the original and 1 copy with the clerk. Keep 1 copy for your records. Notice: You must sign this form under oath. To Clerk: Stamp form on filing. File original as a pending matter and give 1 copy to the Public Defender's Office. Judicial Authority is to assign for hearing within 20 days after filing. Forward written notice of hearing to (1)240trial counsel or applicant, if self-represented, (2) Public Defender's Office to which application was sent, and (3) Chief of Legal Services, Public Defender's Office.Instructions qSTATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov1. I cannot pay the fees, costs and expenses of an appeal (I am indigent), and I cannot afford to hire an attorney. 2. The grounds on which I propose to appeal are:3. The facts about my financial status are:(If more space is needed, attach an affidavit (a sworn statement) saying the grounds on which you propose to appeal.)(If more space is needed, attach an affidavit (a sworn statement) saying the facts about your financial status.)THEREFORE, I ask that the court (1) waive the payment by me of (not require that I pay) the fees specified by statute, taxable costs, and the furnishing of security for costs upon appeal, if security has been ordered under Section 60-9 of the Connecticut Practice Book; (2) appoint counsel to represent me in my appeal without expense to me and permit the withdrawal of the trial attorney's appearance, if any; and (3) order that the necessary expenses of prosecuting the appeal be paid by the State, Sections 63-6 and 63-7 of the Connecticut Practice Book. Appeal From Judgment of Conviction Notice - Unless the court extends the time limit, this application must be completed, signed and filed with the clerk of the Superior Court named below within twenty (20) days from the Date of Judgment. (Show date below.)Appeal From Decision in Habeas Corpus Notice - Unless the court extends the time limit, this application must be completed, signed and filed with the clerk of the Superior Court named below within twenty (20) days from the date the notice was issued of the ruling on your request for certification to appeal. (Show date below.) Date of Judgment Date notice issued (Granting your request for certification) Name and address of court Docket number Name of case Applicant's signature Subscribed and sworn to before me on (Date) Signed (Notary Public/Commissioner of the Superior Court) FOR COURT USE ONLY APPLICATION FOR WAIVER OF FEES, COSTS AND EXPENSES AND APPOINTMENT OF COUNSEL ON APPEAL JD-CR-73 Rev. 1-19 C.G.S. 247 52-259b; P.B. 247247 60-9, 63-1, 63-6, 63-7, 80-1 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2JD-CR-73 Rev. 1-19Shall not be paid by the State.Granted as follows:If necessary expenses are paid by the State, attorneys in private practice representing the applicant shall obtain the approval of the judicial authority who presided at the trial before incurring any expense in excess of $100, including the expense of obtaining a transcript. The judicial authority shall authorize a transcript at State expense only of the portions or proceedings or testimony which may be pertinent to the issues on appeal.Denied. Denied. The application for the payment of fees, costs and expenses of an appeal is DENIED because 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. ORDER(The judicial authority must be satisfied that trial counsel has cooperated fully with appellate counsel in the preparation of the defendant's appeal prior to granting permission.)All fees and costs are waived and the State shall pay all necessary expenses. See paragraph 4 for limits on necessary expenses.5. The court, having found the applicantIndigentNot Indigent, hereby orders the application:Other (Specify):1. The following fees are waived:Appellate filing fee (Supreme or Appellate Court)Cost of the transcript for filing appeal.4. Necessary expenses of prosecuting the appeal 2. Taxable costs areWaivedNot Waived3. Security for costs is WaivedNot WaivedShallDenied.6. CounselIsIs not appointed.7. Permission for the withdrawal of the trial attorney's appearance is Granted By the Court (Print or type name of judge) On (Date) Signed (Judge, Asst. Clerk) Date signed Name of Counsel, If Appointed 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. Name of case Docket number American LegalNet, Inc. www.FormsWorkFlow.com