SUPPLEMENTAL AFFIDAVIT AND REQUEST FOR ORDERS OF MAINTENANCE JD-FM-233 New 1-15 P.A. 14-217 § 120 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov For Court Use Only REQMAIN *REQMAIN* 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. Note to Person Filing Request (Applicant): This form may only be used if you and the respondent are spouses or if you and the respondent live together and have a dependent child or children in common. Instructions to Person Filing Request (Applicant): If you are requesting the court to enter orders to maintain the safety and basic needs of yourself or any dependent child(ren) in your Application for Relief from Abuse (JD-FM-137), complete Section A, and complete Sections B and C as they apply. If you request any orders in Section C of this form, those orders cannot enter on an ex parte basis (prior to a hearing) and will be considered when you have a hearing on your application. Name of Applicant (Last, first, middle initial) Name of Respondent (Last, first, middle initial) Docket Number A. I swear to the following: The respondent is (select all that apply) A person who is also the parent of my dependent child or children in common and we all live together I request that the court enter the following orders because (select all that apply): No other orders exist. An order is necessary to maintain my safety or the safety of any dependent child(ren) in common. An order is necessary to my basic needs or the basic needs of any dependent child(ren) in common. My spouse or a person I have a civil union with B. REQUESTS FOR EX PARTE RELIEF (May also be ordered at the time of the hearing) An order prohibiting the respondent from: Taking any action that could result in the termination of any necessary utility services or necessary services related to the family dwelling or dwelling in which I reside. Taking any action that could result in the cancellation, change of coverage or change of beneficiary of any health, automobile, or homeowner's policy to the detriment of me or any dependent child(ren) the respondent and I have in common. Transferring, encumbering, concealing, or disposing of the property specified which is owned or leased by the applicant. (Specify Below) CT40 CT41 CT42 An order that the respondent provide me with: An automobile (specify) A checkbook (specify) Documentation of health, automobile or homeowner's insurance (specify) A document for the purpose of proving my identity (specify) A key to (specify) The following personal effects (specify) CT43 CT44 CT45 CT46 CT47 CT48 C. REQUESTS FOR RELIEF AT THE TIME OF THE HEARING An order that the respondent be required to: Make rent or mortgage payments on the family dwelling or the dwelling in which I reside with any dependent child(ren) the respondent and I have in common. Maintain utility services or any other necessary services related to the family dwelling or the dwelling in which I reside with any dependent child(ren) that the respondent and I have in common. Maintain all existing health, automobile or homeowner's insurance coverage without change in coverage or beneficiary designation. Provide financial support for the benefit of any dependent child(ren) that the respondent and I have in common provided that the respondent has a legal duty to support such child(ren) and has the ability to pay. CT49 CT50 CT51 CT52 Note: If, at your hearing, no order is entered under section B or C, no such order may be entered thereafter pursuant to this section. Any order entered pursuant to section C shall not be subject to modification. Any order entered pursuant to Sections B and C shall expire at 120 days or sooner as the court may determine after the date of issuance or upon issuance of a superseding order, whichever occurs first. Any amounts ordered but not paid or collected under this section may be preserved and collectable in an action for dissolution of marriage, custody, paternity or support. I certify that the statements above are true to the best of my knowledge and belief. Signature Print name of person signing Subscribed and sworn to before me (Assistant Clerk, Commissioner of Superior Court, Notary Public) Date signed American LegalNet, Inc. www.FormsWorkFlow.com