Page 1 of 3Total Monthly ExpensesJ. Other (medical, dental, child support paid, alimony paid, etc.) (Specify):1.Dependents (another person who is supported by you)2.Monthly Income3.Monthly ExpensesTotal 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 DebtA. 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/PAYMENT OF COSTS/APPOINTMENT OF COUNSEL - FAMILY JD-FM-75 Rev. 1-19 C.G.S. 247247 46b-231, 52-259b P.B. 247247 8-2, 25-63, 63-6STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Judicial DistrictAppointment of Counsel (This applies only in a contempt proceeding or to the putative father in a paternity proceeding.)Financial Affidavit Amount Owed Monthly PaymentTo: The Superior CourtInstructions 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.Instructions to person asking to have the fees waived or for appointment of an attorney (applicant) 1. Print or type all information requested. 2.Sign the Financial Affidavit section in front ofa court clerk, a notary public or an attorney. 3. Bring this form to the superior court where your case will be filed or is/was 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.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 Liabilities5.Liabilities/Debts (for example, credit card balances, loans, etc. Do notinclude mortgage or loan balances that are listed under "Assets".) Estimated Value Loan Balance EquityTotal Assets4.AssetsFee Waiver/Payment of Costs(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. 247 46b-69b Appellate matter (Supreme or Appellate Court)Grounds 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: Appellate filing fee (Supreme or Appellate Court) Cost of the transcript for appeal American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3JD-FM-75 Rev. 1-19The application for waiver of the payment of a fee or fees or the cost of service of process 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.Indigent or unable to pay for parenting education program under C.G.S. 247 46b-69b, hereby orders the application: Not indigent Entry feeI certify that the information in 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 above. Any false statement made by you under oath that you do not believe to be true and that 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. Signed (Applicant)The Court, having found the applicant ("X" all that apply): Notice u Subscribed and sworn to before me: Signed (Notary Public, Commissioner of the Superior Court, Assistant Clerk)Order Granted as follows:Indigent and unable to pay2.The following fees are waived3.All costs for participation in a parenting education program shall be covered by the service provider pursuant to C.G.S.24746b-69b, because the applicant is found indigent or unable to pay.Other (Specify):1.The following costs are ordered paid by the StateCosts of service of process not to exceed: $ Other (Specify):4.Counsel isAppointed (Name): 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 signedFiling fee Print name of person signing at left Date signed On (Date) Denied. If denied only in part, specify: Appellate filing fee (Supreme or Appellate Court) Docket number (If applicable) Name of case 6.If you claim zero Total Monthly Income in number 2 above or zero Total Monthly Expenses in number 3 above, explain howyou are supported: Cost of the transcript for appeal in accordance with Practice Book section 63-6.Request For Hearing On Denied ApplicationThe 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. Signed (Applicant) Date signed 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)u American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3JD-FM-75 Rev. 1-19Order After Hearing Other (Specify): Denied for the following reason(s): By the Court (Print or type name of Judge/FSM) On (Date) Signed (Judge, FSM, Assistant Clerk) Date signedhereby orders the application:Not indigent The Court, having found the applicant Granted as follows:Indigent and unable to pay2.The following fees are waived1.The following costs are ordered paid by the StateCosts of service of process not to exceed $ Entry fee Other (Specify):Filing fee The application for waiver of the payment of a fee or fees or the cost of service of process 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. Docket number (If applicable) Name of case Cost of the transcript for appeal in accordance with Practice Book Section 63-6.Appel