(Page 1 of 2) Name of employerAPPLICATION FOR APPOINTMENT OF COUNSEL/WAIVER OF FEES/PAYMENT OF COSTS - JUVENILE JD-JM-114 Rev. 1-19 C.G.S. 247247 46b-135, 136, 51-289a, 53a-157b, 52-259b P.B. 247247 8-2, 30a-1, 32a-1Financial AffidavitTo: The Superior Court Instructions To Clerk 1. Bring completed form to a judge. 2. If the application is granted, notify the applicant and counsel, if appointed. 3. If the application is denied, and upon the request of the applicant, schedule a hearing on the application. Instructions To Applicant 1. Print or type all information requested. 2. Sign the Financial Affidavit section in front of a court clerk, a notary public or an attorney. 3. Submit this form immediately in person, by mail or fax to the superior court where your case will be filed or is/was pending. 4. If your application is denied, you may request a hearing on the application.1. Dependents2. Gross Monthly Income and Assistance - Applicant Total number of dependents (not including yourself) Number of dependents under 18........................... Relationship to child* Total Gross Monthly Income of all adult members of the household: (Add Total Monthly Income of Applicant and any other adults in the household) Total Gross Monthly Income.......................D. Unemployment Compensation...................E. Worker's Compensation...........................G. Pension................................................H. Child Support.........................................I. Alimony.................................................F. Social Security........................................STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.govA. Employment...........................................B. State/City Assistance...............................C. SSI...................................................... Name of applicant (Last, first, middle initial) Date of birth Address of applicant (Number, street, town, state and zip) Address of employer (Number, street, town, state and zip) Telephone (Area code first) Mother Father Legal guardian Other Telephone (Area code first) Name of child Date of birth Name of child Date of birth Name of child Date of birth Docket number (If applicable) Address of court Number of other dependents............................... 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 Other (Specify): Appointment of Counsel I ask that the court order that I do not have to pay fees or costs or order the State to pay the fees and costs below. ("X" all that apply)Fee Waiver/Payment of Costs Entry fee (fee to file case) Filing fee (fee to file motion, etc.) Costs of service of process (delivery of papers by state marshal or other proper officer) Other (Specify): I ask that the court appoint an attorney to represent me.3. Gross Monthly Income and Assistance - Totals Other Adult Household Members Total Gross Monthly Income......................D. Unemployment Compensation..................E. Worker's Compensation...........................G. Pension................................................H. Child Support.........................................I. Alimony.................................................F. Social Security.......................................A. Employment..........................................B. State/City Assistance...............................C. SSI...................................................... Name of employer: Appeal from Juvenile Court Decision Appellate filing fee (Supreme or Appellate Court) Cost of the transcript for appealGrounds for Appeal (Complete if requesting waiver of Appellate filing fee (Supreme or Appellate Court) and/or payment of cost of the transcript for appeal)The grounds on which I propose to appeal are: *If you claim zero Total Monthly Income, explain how you are supported:Please attach copy of recent paystub(s) if available. Application American LegalNet, Inc. www.FormsWorkFlow.com (Page 2 of 2)JD-JM-114 Rev. 1-19Cost of the transcript for appeal in accordance with Practice Book Section 63-6.Not indigent and able to payEntry feeI certify that the information on this application is accurate to the best of my knowledge and that I can, if requested, document all income, assets, and liabilities listed on this application. Any false statement made by you 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. Signed (Applicant)The Court, having found the applicant ("x" all that apply) Notice u Print name of person signing at left Date signed Subscribed and sworn to before me: On (Date) Signed (Notary Public, Commissioner of the Superior Court, Assistant Clerk)OrderGranted as follows:Indigent and unable to pay2. The following fees are waived (including additional $5.00, if required)Other (Specify:)3. The following fees/costs are ordered paid by the State Marshal's fee not to exceed $Other (Specify:)1. Counsel is Appointed in the interests of justice pursuant to Connecticut General Statutes Section 46b-136.Appointed Denied. By the Court (Print or type name of Judge) On (Date) Signed (Judge, Ass't Clerk) Date signedFiling fee hereby orders the application: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. Cost of the transcript for appeal. Appellate filing fee (Supreme or Appellate 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. Type of Debt Amount Owed Weekly PaymentTotal Liabilities5. Liabilities/Debts - Applicant(for example, credit card balances, loans, etc.) (Do not include mortgage or loan balances that are listed under "Assets".) A. Real Estate.......B. Motor Vehicles..C. Other Personal Property............(for example, jewelry, furniture, etc.) D. Savings Account Balance (Total of all accounts)..E. Checking Account Balance (Total of all accounts) F. Other Assets (Specify stocks, bonds, trust, cd's):. Estimated Value Loan Balance EquityTotal Assets...................................................4. Assets - Applicant Address: Year/Make: American LegalNet, Inc. www.FormsWorkFlow.com