AFFIDAVIT OF INDIGENCY — FEE WAIVER, CRIMINAL STATE OF CONNECTICUT SUPERIOR COURT JD-AP-48 Rev. 10-10 C.G.S. §§ 54-56g, 52-259b www.jud.ct.gov Instructions to Applicant: 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 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 Specify fee to be waived (Copies, transcript, program fee, etc.) Net income I. $ Income (Net income after taxes; include all sources)... ...................... Public Assistance Received: No Yes (If yes, specify type): Number of dependents II. Dependents (Total number of dependents)........................................ III. Assets Estimated Value Mortgage Balance Equity Real estate $ A. Real Estate......................... $ $ Motor vehicle $ B. Motor Vehicles.................... $ $ Other $ C. Other personal property...... $ $ Savings $ D. Savings accounts (Total of all accounts )................................................ Checking $ E. Checking accounts (Total of all accounts).............................................. Stock value $ F. Stocks: Name Bond value $ G. Bonds: Name Total assets $ IV. Liabilities Source Date 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: Any false statement you make under oath which you do not believe to be true and which 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. (Attach Pertinent Records) Print name of person signed at left Signed (Applicant) Subscribed and sworn to before me: On (Date) Print Form Date signed Signed (Notary Public, Commissioner of Superior Court, Assistant Clerk) Page 1 of 2 Reset Form American LegalNet, Inc. www.FormsWorkFlow.com Pursuant to General Statutes § 52-259b, 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, food stamps and Supplemental Security Income." Order of Court The Court, having found the applicant hereby orders the application: Indigent and unable to pay Not indigent Granted as follows: 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 By the Court (Print name of Judge) Date signed Signed (Judge, Assistant Clerk) On (Date) 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. Date signed Signed (Applicant) Superior Court Judicial District or Geographical Area number Date of hearing Hearing To Be Held At Time of hearing Address of court (Number, street and town) Signed (Assistant Clerk) Room number Order Of Court After Hearing The Court, having found the applicant hereby orders the application: Indigent and unable to pay Not indigent Granted as follows: 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 By the court (Print name of Judge) On (Date) Date signed Signed (Judge, Assistant Clerk) JD-AP-48 (back/page 2) Rev. 10-10 Print Form Page 2 of 2 Reset Form American LegalNet, Inc. www.FormsWorkFlow.com