JD-AP-48 Rev. 8-15 C.G.S. §§ 54-56g, 52-259b AFFIDAVIT OF INDIGENCY -- FEE WAIVER, CRIMINAL STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Instructions to Person Applying for Waiver: Print or type all information and sign affidavit in front of court clerk, notary public, or an attorney. Instructions to Clerk: If application is denied and a hearing is requested, schedule hearing and issue notice of hearing. Name of case Specify fee to be waived (Copies, transcript, program fee, etc.) 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 If the request is for a transcript or for copies, what will the transcript or copies be used for? I. Income (Net income after taxes; include all sources) ....................................... No Yes Public Assistance Received: (If yes, specify type): Net income $ Number of dependents II. Dependents (Total number of dependents)..................................................... III. Assets A. Real Estate ............................ $ B. Motor Vehicles........................ C. Other personal property............ Estimated Value Mortgage Balance Real estate Equity $ $ $ $ Motor vehicle $ $ $ Other $ Savings D. Savings accounts (Total of all accounts) ........................................................ E. Checking accounts (Total of all accounts)....................................................... F. Stocks: Name G. Bonds: Name $ Checking $ Stock value $ Bond value $ Total assets IV. Liabilities (Debts) Date Source Amount of Debt $ Balance Due Weekly Payment $ $ $ $ $ $ $ $ $ $ Total liability $ $ $ $ $ $ V. Affidavit I certify that the information above is accurate to the best of my knowledge and that I can, if requested, submit documentation for all income, assets and liabilities listed above. Notice: (Attach relevant records) Signed (Applicant) Any false statement you make 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. Print name of person signed at left On (Date) Date signed Subscribed and sworn to before me: Signed (Notary Public, Commissioner of Superior Court, Assistant Clerk) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com For purposes of determining whether a party is indigent and unable to pay a fee to the court or to pay the cost of service: "There shall be a rebuttable presumption that a person is indigent and unable to pay a fee or fees or the cost of service of process if (1) such person receives public assistance or (2) such person's income after taxes, mandatory wage deductions and child care expenses is one hundred twenty-five per cent or less of the federal poverty level. For purposes of this subsection, "public assistance" includes, but is not limited to, state-administered general assistance, temporary family assistance, aid to the aged, blind and disabled, supplemental nutrition assistance, and Supplemental Security Income." Section 52-259b(b) of the Connecticut General Statutes. Order of Court The Court, having found the applicant orders the application: Granted as follows: Indigent and unable to pay Not indigent 1. The following fees payable to the court are waived. (specify: ) ___________________________________ 2. The following fees are ordered paid by the State: service of process not to exceed $________________ (specify amount if limited) other (specify:) ___________________________________________________ Denied Denied: 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. By the Court (Print name of Judge) On (Date) Signed (Judge, Assistant Clerk) Date signed Request For Hearing On Fee Waiver Application (Only if initially denied without a hearing) I request a court hearing on the application for a fee waiver. Signed (Applicant) Superior Court Judicial District or Geographical Area number Date of hearing Date signed Time of hearing Signed (Assistant Clerk) Room number Hearing To Be Held At Address of court (Number, street and town) Order Of Court After Hearing The Court, having found the applicant orders the application: Granted as follows: Indigent and unable to pay Not indigent 1. The following fees payable to the court are waived. (specify: ) ___________________________________ 2. The following fees are ordered paid by the State: service of process not to exceed $________________ ( specify amount if limited) other (specify:) ___________________________________________________ Denied Denied: 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. By the court (Print name of Judge) On (Date) Signed (Judge, Assistant Clerk) Date signed JD-AP-48 (back/page 2) Rev. 8-15 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com