Click here to get more information about the fields on this form. FINANCIAL AFFIDAVIT JD-FM-6-SHORT Rev. 2-16 P.B. §§ 25-30, 25a-15 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Court Use Only FINAFFS Instructions Use this short version if your gross annual income is less than $75,000 (see Section I. Income) and your total net assets are less than $75,000 (see Section IV. Assets). Otherwise, use the long version, form JD-FM-6-LONG. For the Judicial District of Name of case Name of affiant (Person submitting this form) At (Address of Court) 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. Docket number *FINAFFS* - FA - - -S Plaintiff Defendant Certification I understand that the information stated on this Financial Statement and the attached Schedules, if any, is complete, true, and accurate. I understand that willful misrepresentation of any of the information provided will subject me to sanctions and may result in criminal charges being filed against me. I. Income 1) Gross Weekly Income/Monies and Benefits From All Sources Computed based on year-to-date, but no less than the last 13 weeks. If computation is based on less than 13 weeks or if your computations are not reflective of current wages, explain: Paid: Weekly Bi-weekly Monthly Semi-monthly Annually If income is not paid weekly, adjust the rate of pay to weekly as follows: Bi-weekly divide by 2 Monthly multiply by 12, divide by 52 (a) Job 1 Job 2 Job 3 (b) (c) (d) (e) (f) (g) (h) (i) Overtime .............................................. Self-employment ................................... Tips...................................................... Social Security ...................................... Disability............................................... Unemployment ..................................... Worker's compensation ......................... Public Assistance (Welfare, TFA payments) ............................................ $ $ $ $ $ $ $ $ (j) (k) (l) (m) (n) (o) (p) Employer Semi-monthly multiply by 2, multiply by 12, divide by 52 Annually divide by 52 Address Salary Salary Salary Base Pay: Wages $ Wages $ Wages $ Total of base pay from salary and wages of all jobs............................................................................ $ Child Support (Actually received)............ Alimony (Actually received) .................... Rental and income producing property.... Contributions from household member(s) Cash income ......................................... Veterans Benefits .................................. Other: $ $ $ $ $ $ $ (q) Total Gross Weekly Income/Monies and Benefits From All Sources (Add items a through p) $ Hours worked per week Gross yearly income from prior tax year. Provide amount of income, not copies of forms ............................... $ List here and explain any other income including but not limited to: non-reported income; and support provided by relatives, friends, and others: (Page 1 of 4) American LegalNet, Inc. www.FormsWorkFlow.com 2) Mandatory Deductions (If consistent deductions don't occur every pay check provide average amounts.) (1) Federal income tax deductions (claiming exemptions) (2) Social Security or Mandatory Retirement (3) State income tax deductions exemptions) (claiming (4) Medicare (5) Health insurance (6) Union dues (7) Prior court order -- child support or alimony (8) Total Mandatory Deductions (add items 1 through 7) $ $ $ $ $ $ $ $ Job 1 $ $ $ $ $ $ $ $ Job 2 $ $ $ $ $ $ $ $ Job 3 $ $ $ $ $ $ $ $ Totals 3) Net Weekly Income.............................................................................................................................. $ Subtract the Total Mandatory Deductions [see item I., 2), (8)] from the Total Gross Weekly Income/Monies and Benefits From All Sources [see item I., 1), q) ] If expenses are not paid weekly, adjust the rate of payment to weekly as follows: Bi-weekly divide by 2 Semi-monthly multiply by 2, multiply by 12, divide by 52 Monthly multiply by 12, divide by 52 Annually divide by 52 Insert an ("x") in the box if you are not currently paying the expense, or if someone else is paying the expense. Home: Rent or Mortgage (Principal, Interest -- $ $ Property taxes and assessments ........... Real Estate Taxes and Insurance if escrowed) Utilities: Telephone/Cell/Internet............................ $ $ Oil ........................................................ Electricity .............................................. Trash Collection ...................................... $ $ $ $ Gas ...................................................... T.V./Internet ............................................ Water and Sewer................................... $ Groceries (after food stamps): Including household supplies, formula, diapers ......................................... $ Transportation: Auto Loan or Lease ................................. Gas/Oil ................................................. $ $ $ $ Repairs/Maintenance ............................. Public Transportation............................... Automobile Insurance/Tax/Registration ... $ Insurance Premiums: Medical/Dental (Out-of-pocket expense Life ......................................................... $ $ after Health Savings Account/Plan)....... $ Uninsured Medical/Dental not paid by insurance ................................................................................... Clothing ............................................................................................................................................. $ Child(ren): Child Care Expense (after deductions, Child Support of this case ..................... $ $ credits and subsidies)............................ Child Support of other children other than Child(ren)'s activities (e.g., lessons, sports, $ $ this case (attach a copy of the order) ... etc.) ..................................................... Alimony: Payable to this spouse ............... $ Alimony: Payable to another spouse ....... $ $ Extraordinary travel expenses for visitation with child(ren) ........................................................................ Other (Specify): $ Total Weekly Expenses Not Deducted From Pay ............................................................................