Fillable APPLICATION FOR WAIVER OF FEES/ PAYMENT OF COSTS/APPOINTMENT (State of Connecticut/Department of Administrative Services)

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APPLICATION FOR WAIVER OF FEES/ PAYMENT OF COSTS/APPOINTMENT (State of Connecticut/Department of Administrative Services)

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BROWSE STATE OF CONNECTICUT/DEPARTMENT OF ADMINISTRATIVE SERVICES (CT) FORMS

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Page 1 of 3
Total Monthly Expenses
J. Other
(medical, dental, child support paid,
alimony paid, etc.) (Specify):
1. Dependents (another person who is supported by you)
2. Monthly Income
3. Monthly Expenses
Total number of dependents (not including yourself)
A. Gross monthly income (before
deductions)
B. Net monthly income after taxes
from monthly employment
C. Other income (for example, TANF,
Social Security, child support, alimony,
etc.) (Specify which one(s) here):
Total Monthly Income (B+C)
A. Rent/Mortgage
B. Real Estate Taxes
C. Utilities
(telephone, fuel heat, electric,
water, gas, cable, etc.)
D. Food (less SNAP (food stamps), if any)
E. Clothing
F. Insurance Premiums (medical/dental,
auto, life, home)
G. Medical/Dental
H. Transportation (bus, gasoline, etc.)
I. Child Care
Type of Debt
A. Real Estate
B. Motor Vehicles
C. Other Personal
Property
D. Savings Account Balance (Total of all accounts)
E. Checking Account Balance (Total of all accounts)
F. Cash
G. Other Assets (Specify):
Type of proceeding
("x" all that apply)
APPLICATION FOR WAIVER OF FEES/
PAYMENT OF COSTS/APPOINTMENT
OF COUNSEL - FAMILY
JD-FM-75 Rev. 1-19
C.G.S. §§ 46b-231, 52-259b
P.B. §§ 8-2, 25-63, 63-6
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
Judicial District
Appointment of Counsel (This applies only in a contempt proceeding or to the putative father in a paternity proceeding.)
Financial Affidavit
Amount Owed
Monthly
Payment
To: The Superior Court
Instructions to Clerk
1. Bring completed form to a judge or, if applicable, to a
family support magistrate.
2. If the application is granted, notify the applicant and
counsel, if appointed.
3. If the application for fees payable to the court or for costs
of service of process is denied, and upon the request of
the applicant, schedule a hearing on the application.
Instructions to person asking to have the fees
waived or for appointment of an attorney
(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. Bring this form to the superior court where your
case will be filed or is/was pending.
4. If your application for fees payable to the court
or for costs of service of process is denied, you
may ask for a hearing on the application.
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)
Total Liabilities
5. Liabilities/Debts (for example, credit card balances, loans, etc. Do not
include mortgage or loan balances that are listed under "Assets".)
Estimated Value Loan Balance Equity
Total Assets
4. Assets
Fee Waiver/Payment of Costs
(for example, jewelry, furniture, etc.)
Name of case
Docket number (If applicable)
Address of court
Name of applicant (Last, first, middle initial) Address of applicant (Number, street, town, state and zip) Telephone (Area code first)
Contempt Motion to Open or Modify
Other (Specify):
Dissolution of Marriage (Divorce)
Dissolution of Civil Union
Application for Custody
Application or Petition for Visitation
Paternity
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 (For example costs of notice by publication or for a certified copy of judgment, etc.) (Specify):
I ask that the court appoint an attorney to represent me.
Real Estate
Motor Vehicle
Other Property
Savings
Checking
Cash
Other Assets
This form must be used only for family and family
support magistrate matters. For civil, housing and small
claims matters, use form JD-CV-120.
Costs for participating in parenting education under C.G.S. § 46b-69b
Appellate matter (Supreme or Appellate Court)
Grounds 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:
Appellate filing fee (Supreme or Appellate Court) Cost of the transcript for appeal
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Page 2 of 3JD-FM-75 Rev. 1-19
The application for waiver of the payment of a fee or fees or the cost of service of process is DENIED because the 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.
Indigent or unable to pay for parenting education program under C.G.S. § 46b-69b, hereby orders the application:
Not indigent
Entry fee
I certify that the information in this application is true and accurate to the best of my knowledge and that I can, if asked, document all
income, expenses, and liabilities listed above.
Any false statement made by you 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.
Signed (Applicant)
The Court, having found the applicant ("X" all that apply):
Notice u
Subscribed and sworn
to before me:
Signed (Notary Public, Commissioner of the Superior Court, Assistant Clerk)
Order
Granted as follows:
Indigent and unable to pay
2. The following fees are waived
3.
All costs for participation in a parenting education program shall be covered by the service provider pursuant to C.G.S.
§ 46b-69b, because the applicant is found indigent or unable to pay.
Other (Specify):
1. The following costs are ordered paid by the State
Costs of service of process not to exceed: $
Other (Specify):
4. Counsel is
Appointed (Name):
Counsel is not appointed because the applicant does not face potential incarceration.
By the Court (Print or type name of Judge/Fam. Sup. Magistrate) On (Date) Signed (Judge, FSM, Assistant Clerk)
Date signed
Filing fee
Print name of person signing at left Date signed
On (Date)
Denied. If denied only in part, specify:
Appellate filing fee (Supreme or Appellate Court)
Docket number (If applicable)
Name of case
6. If you claim zero Total Monthly Income in number 2 above or zero Total Monthly Expenses in number 3 above, explain how
you are supported:
Cost of the transcript for appeal in accordance with Practice Book section 63-6.
Request For Hearing On Denied Application
The following section applies only to a denial of the application for waiver of fees payable to the court or for the costs of service of process.
It does not apply to applications for fee waiver for parenting education or to appointment of counsel.
I request a court hearing on the application.
Signed (Applicant)
Date signed
Hearing to be held at the Court location shown on page 1 on the date and time shown below:
Hearing on (Date) At (Time)
Room number
Signed (Assistant Clerk)
u
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Page 3 of 3JD-FM-75 Rev. 1-19
Order After Hearing
Other (Specify):
Denied for the following reason(s):
By the Court (Print or type name of Judge/FSM)
On (Date) Signed (Judge, FSM, Assistant Clerk)
Date signed
hereby orders the application:Not indigent The Court, having found the applicant
Granted as follows:
Indigent and unable to pay
2. The following fees are waived
1. The following costs are ordered paid by the State
Costs of service of process not to exceed $
Entry fee
Other (Specify):
Filing fee
The application for waiver of the payment of a fee or fees or the cost of service of process is DENIED because the 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.
Docket number (If applicable)
Name of case
Cost of the transcript for appeal in accordance with Practice Book Section 63-6.
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.
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APPLICATION FOR WAIVER OF FEES PAYMENT OF COSTSAPPOINTMENT (State of ConnecticutDepartment of Administrative Services)

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Completed 30 July 2021

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