REQUEST FOR HEARING, DENIED APPLICATION FOR COUNSEL OR WAIVER OF FEES -- JUVENILE JD-JM-114A Rev. 11-11 C.G.S. �� 46b-135, 136, 53a-157b, � 52-259b, P.A. 11-51, Sec. 19; P.B. �� 8-2, 30a-1, 32a-1 STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov Instructions To Person Applying for Counsel or Waiver of Fees 1. If your application for counsel or waiver of fees is denied you may request a hearing on your application using this form. 2. Print or type all information requested. 3. Sign the Request for Hearing section. 4. Submit this form in person, by mail or fax to the superior court where your case will be filed or is pending. Instructions To Clerk 1. Upon receipt of this form, schedule a hearing on the application and notify the applicant. 2. After the hearing, give a copy of this form containing the Court Order to the applicant. 3. If the application is granted, notify the applicant and 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. To: The Superior Court Name of applicant (Last, first, middle initial) Name of employer Relationship to child Date of birth Address of applicant (Number, street, town, state and zip) Telephone (Area code first) Telephone (Area code first) Address of employer (Number, street, town, state and zip) Mother Name of child Father Legal guardian Date of birth Address of Court Name of child Other Date of birth Name of child Date of birth Docket number (If applicable) Type of proceeding Delinquency Family with service needs Emancipation Neglect, uncared-for, abused petition Termination of parental rights petition Probate appeal Probate transfer Transfer/Reinstatement of guardianship Appeal from Juvenile Court Decision Other (Specify): Request For Hearing On Denied Application I request a court hearing on the Application for Appointment of Counsel/Waiver of Fees denied on Date Signed (Applicant) Date signed . HEARING TO BE HELD AT THE COURT LOCATION SHOWN ON THE DATE AND TIME SHOWN BELOW: Hearing on (Date) At (Time) Signed (Assistant Clerk) Order After Hearing The Court, having found the applicant ("x" all that apply) Indigent and unable to pay Granted as follows: 1. Counsel is Appointed Appointed in the interests of justice pursuant to Connecticut General Statutes Section 46b-136. The applicant is ordered to reimburse the Public Defender Services Commission at its approved rate for the costs of providing an attorney and said costs shall be payable upon receipt of an invoice from the Public Defender Services Commission. 2. The following fees are waived Entry fee Filing fee Other (Specify:) Not indigent and able to pay hereby orders the application: 3. The following fees are ordered paid by the State Other (Specify:) Denied. By the Court (Print or type name of Judge) On (Date) Marshal's fee not to exceed $ Signed (Judge, Ass't Clerk) Date signed American LegalNet, Inc. www.FormsWorkFlow.com