Fillable Fm006-short FINANCIAL AFFIDAVIT (LESS THAN $75,000)

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Fm006-short FINANCIAL AFFIDAVIT (LESS THAN $75,000)

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FINANCIAL AFFIDAVIT
JD-FM-6-SHORT Rev. 2-16
P.B. §§ 25-30, 25a-15
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
FINAFFS
Court Use Only
*FINAFFS*
Instructions
Use this short version if your gross annual income is less than $75,000 (see Section I.
Income) and your total net assets are less than $75,000 (see Section IV. Assets).
Otherwise, use the long version, form JD-FM-6-LONG.
Docket number
- FA - - S-
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.
For the Judicial District of
At (Address of Court)
Name of case
Name of affiant (Person submitting this form)
Plaintiff Defendant
Certification
I understand that the information stated on this Financial Statement and the attached Schedules, if any, is complete, true, and
accurate. I understand that willful misrepresentation of any of the information provided will subject me to sanctions
and may result in criminal charges being filed against me.
I. Income
1) Gross Weekly Income/Monies and Benefits From All Sources
Computed based on year-to-date, but no less than the last 13 weeks. If computation is based on less than 13 weeks or if
your computations are not reflective of current wages, explain:
Paid:
Weekly Bi-weekly Monthly Semi-monthly Annually
If income is not paid weekly, adjust the rate of pay to weekly as follows:
Bi-weekly → divide by 2 Semi-monthly → multiply by 2, multiply by 12, divide by 52
Monthly → multiply by 12, divide by 52 Annually → divide by 52
(a) Employer Address Base Pay:
Job 1 $
Salary Wages
Job 2 $
Salary Wages
Job 3 $
Salary Wages
Total of base pay from salary and wages of all jobs............................................................................
$
(b) Overtime ..............................................
$
(c) Self-employment...................................
$
(d) Tips......................................................
$
(e) Social Security......................................
$
(f) Disability...............................................
$
(g) Unemployment .....................................
$
(h) Worker's compensation .........................
$
(i)
Public Assistance (Welfare, TFA
payments) ............................................
$
(j)
Child Support (Actually received)............
$
(k)
Alimony (Actually received) ....................
$
(l)
Rental and income producing property....
$
(m) Contributions from household member(s)
$
(n) Cash income.........................................
$
(o) Veterans Benefits ..................................
$
(p) Other:
$
(q)
Total Gross Weekly Income/Monies and Benefits From All Sources (Add items a through p)
$
Hours worked per week
Gross yearly income from prior tax year. Provide amount of income, not copies of forms ............................... $
List here and explain any other income including but not limited to: non-reported income; and support provided by relatives,
friends, and others:
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(Page 2 of 4)
JD-FM-6-SHORT Rev. 2-16
2) Mandatory Deductions
(If consistent deductions don't occur every pay check provide average amounts.)
(1) Federal income tax deductions
Job 1
$
$
$
$
$
$
$
$
Job 2
$
$
$
$
$
$
$
$
Job 3
$
$
$
$
$
$
$
$
$
Totals
(claiming exemptions)
$
$
$
$
(2) Social Security or Mandatory Retirement
(3) State income tax deductions
$
(claiming
exemptions)
(4) Medicare
(5) Health insurance
(6) Union dues
(7) Prior court order — child support or alimony
(8) Total Mandatory Deductions
(add items 1 through 7)
$
$
3) Net Weekly Income..............................................................................................................................
$
Subtract the Total Mandatory Deductions [see item I., 2), (8)] from the Total Gross Weekly Income/Monies and Benefits
From All Sources [see item I., 1), q) ]
II. Weekly Expenses Not Deducted From Pay
If expenses are not paid weekly, adjust the rate of payment to weekly as follows:
Bi-weekly → divide by 2 Semi-monthly → multiply by 2, multiply by 12, divide by 52
Monthly → multiply by 12, divide by 52
Annually → divide by 52
Insert an ("x") in the box if you are not currently paying the expense, or if someone else is paying the expense.
Home:
Rent or Mortgage (Principal, Interest —
Real Estate Taxes and Insurance if
escrowed)
$
Property taxes and assessments ...........
$
Utilities:
Oil ........................................................ $
Electricity ..............................................
$
Gas ......................................................
$
Water and Sewer...................................
$
Telephone/Cell/Internet............................
$
Trash Collection ......................................
$
T.V./Internet ............................................
$
Groceries
(after food stamps): Including household supplies, formula, diapers .........................................
$
Transportation:
Gas/Oil .................................................
$
Repairs/Maintenance .............................
$
Automobile Insurance/Tax/Registration ...
$
Auto Loan or Lease .................................
$
Public Transportation...............................
$
Insurance Premiums:
Medical/Dental (Out-of-pocket expense
after Health Savings Account/Plan).......
$
Life .........................................................
$
Uninsured Medical/Dental not paid by insurance ...................................................................................
$
Clothing .............................................................................................................................................
$
Child(ren):
Child Support of this case .....................
$
Child Care Expense (after deductions,
credits and subsidies)............................
$
Child Support of other children other than
this case (attach a copy of the order) ...
$
Child(ren)'s activities (e.g., lessons, sports,
etc.) .....................................................
$
Alimony: Payable to this spouse ...............
$ Alimony: Payable to another spouse ....... $
Extraordinary travel expenses for visitation with child(ren) ........................................................................
$
Other (Specify):
$
Total Weekly Expenses Not Deducted From Pay ...................................................................................
$
III. Liabilities (Debts)
Do not include expenses listed above. Do not include mortgage current principal balance or loan balances that are listed
under “Assets.”
Creditor Name /Type of Debt Balance Due
Date Debt
Incurred/
Revolving
Weekly
Payment
Credit Card, Consumer, Tax, Health Care, Other Debt
Sole Joint $ $
Sole Joint $ $
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(Page 3 of 4)
JD-FM-6-SHORT Rev. 2-16
Sole Joint $ $
Sole Joint $ $
Sole Joint $ $
(A). Total Liabilities
(Total Balance Due on Debts) ...................................
$
(B). Total Weekly Liabilities Expense ...................................................................................................
$
IV. Assets
Note: Under "Ownership" indicate S for sole, JTS for joint with spouse, and JTO for joint with other.
You must complete the last column to the right "Value of Your Interest" in each applicable section.
A. Real Estate (including time share)
Address
Ownership
S JTS JTO
a. Fair Market
Value (Estimate)
b. Mortgage
Current Principal
Balance
c. Equity Line of
Credit and Other
Liens
d. Equity
(d = a minus (b + c))
e. Value of Your
Interest
Home
$ $ $ $ $
Other
$ $ $ $ $
$ $ $ $ $
Total Net Value of Real Estate: $
B. Motor Vehicles
Year Make Model
JTOJTSS
Ownership
a. Value b. Loan Balance
c. Equity
(c = a minus b)
d. Value of Your
Interest
1: $ $ $ $
2: $ $ $ $
Total Net Value of Motor Vehicles: $
C. Bank Accounts
Do not include custodial accounts or child(ren)'s assets — complete Section V. below.
Institution
Account Number
(last 4 numbers only)
Ownership
S JTS JTO
Current Balance/
Value
Value of Your
Interest
Checking
$ $
Savings
$ $
Other
$ $
Total Net Value of Bank Accounts: $
D. Stocks, Bonds, Mutual Funds
Company
Account Number
(last 4 numbers only)
Listed Beneficiary
Current Balance/
Value
$
$
Total Net Value of Stocks, Bonds, Mutual Funds: $
E. Insurance
(exclude children) D = Disability L = Life
Name of Insured D L Company
Account Number
(last 4 numbers only)
Listed Beneficiary
Current Balance/
Value
$
$
Total Net Value of Insurance: $
F. Retirement Plans
(Pensions on Interest, Individual IRA, 401K, Keogh, etc.)
Type of Plan Name of Plan/Bank/Company
Account Number
(last 4 numbers only)
Listed Beneficiary
Receiving
Payments
Current Balance/
Value
Yes No
$
Yes No
$
Total Net Value of Retirement Plans: $
G. Business Interest/Self-Employment
If you own an interest in a business, or are self-employed, complete this section.
Name of Business Percent Owned Value
%
$
Total Net Value of Business Interest/Self-Employment: $
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(Page 4 of 4)
JD-FM-6-SHORT Rev. 2-16
H. Other Assets
Name of Asset
Current Balance/
Value
Name of Asset
Current Balance/
Value
$ $
$ $
$ $
$ $
Total Net Value of Other Assets: $
I. Total Net Value All Assets (add items A through H)...............................................................................
$
V. Child(ren)'s Assets
Include Uniform Gift to Minor Account, Uniform Trust to Minor Account, College Accounts/529 Account, Custodial Account,
etc.
Institution
Account Number
(last 4 numbers only)
Listed Beneficiary
Person Who Controls the Account
(Fiduciary)
Current Balance/
Value
$
$
Total Net Value of Child(ren)'s Assets: $
VI. Health (Medical and/or Dental Insurance)
Company Name of Insured Person(s) Covered by the Policy
Do you or any member of your family have HUSKY Health Insurance Coverage?
If Yes, whom?
Yes No I Don't Know
Important:
If you have other financial information that has not yet been disclosed, you have an affirmative duty to disclose that
information. List additional information below:
Summary (Use the amounts shown in Sections I. through IV.)
Total Net Weekly Income (See Section I. 3) ...............................................................................................
$
Total Weekly Expenses and Liabilities (Total From Section II. + III.(B)) ......................................................
$
Total Cash Value of Assets (See Section IV. I.) .........................................................................................
$
Total Liabilities (Total Balance Due on Debts) (See Section III. (A)).............................................................
$
Certification
I certify under the penalties of perjury that the information stated on this Financial Statement and the attached Schedules, if
any, is complete, true, and accurate. I understand that willful misrepresentation of any of the information provided will
subject me to sanctions and may result in criminal charges being filed against me.
I,
the Plaintiff Defendant herein, residing at
, telephone number , being duly
sworn, depose and say that the following is an accurate statement of my income from all sources, my liabilities, my assets
and my net worth, from whatever sources, and whatever kind and nature, and wherever situated.
Signed (Affiant)
Date signed
Signed (Notary, Commissioner of Superior Court, Assistant Clerk, Other
Proper Officer under Section 1-24 of the Connecticut General Statutes)
Print name and title of person signing at left Date signed
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Fm006-short FINANCIAL AFFIDAVIT (LESS THAN $75,000)

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Completed 6 April 2020

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