JD-FM-75H Rev. 1-19
Assets are property that you own. Here you must list any valuable property you own. If you don't know the
exact amount that the property is worth, you may put in an amount you think it is worth (an estimate).
This is the value of your property minus the amount you owe on the property. For example, if you own
property that is worth $150,000 but you owe $100,000 on it, then you have $50,000 equity in your property.
This would include the value of any insurance policies; stocks and mutual funds; pension or retirement plans,
including IRAs or KEOGH plans, and other similar kinds of assets.
Add the amounts in boxes A, B, C, D, E, F and G in this section and put the total here.
Liabilities are debts you owe. Think of every person or company you owe money to and list them here. Don't
forget to include such things as overdue utility bills, tax bills, personal and student loans, credit card bills, store
credit card bills, outstanding medical bills, and other similar kinds of debts you owe.
Add up the amounts in these columns and put the total here.
To declare that something is true.
False Statement Punishable
Section 53a-157b of the Connecticut General Statutes says “(a) A person is guilty of false statement when
such person (1) intentionally makes a false written statement that such person does not believe to be true with
the intent to mislead a public servant in the performance of such public servant's official function, and (2)
makes such statement under oath or pursuant to a form bearing notice, authorized by law, to the effect that
false statements made therein are punishable. (b) False statement is a class A misdemeanor.”
Do not sign this form until you are with a notary public, a court clerk or an attorney and they agree to sign it
The court fills out this part of the form after it makes a decision on your application.
Request For Hearing On Denied Application
If the court denies or doesn’t grant your request for you to not have to pay certain fees, or if the court denies
or doesn’t grant your request to have the court pay for delivery (or service) of papers, you can ask the court
for a hearing to explain to a judge or magistrate why you think your application should have been granted.
Order After Hearing
If the court holds a hearing on your denied application, the court fills out this part of the form with its decision.