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

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HELP TEXT FOR APPLICATION FOR WAIVER OF FEES/PAYMENT (State of Connecticut/Department of Administrative Services)

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HELP TEXT FOR APPLICATION FOR WAIVER
OF FEES/PAYMENT OF COSTS/APPOINTMENT
OF COUNSEL - FAMILY
JD-FM-75H Rev. 1-19
APPLICATION FOR WAIVER OF FEES/PAYMENT OF COSTS/APPOINTMENT OF COUNSEL - FAMILY
This form is used in family cases:
(1) to ask the court to not require you to pay certain fees; or
(2) to ask the court to pay certain fees for you, or
(3) to ask the court to appoint an attorney to represent you.
Name of Case
When a lawsuit is filed in court, it must have a name to identify it. Most lawsuits are named the following way:
the name of the person filing the lawsuit, followed by the letter “v”, followed by the name of the person being
sued. For example, in the case named “Smith v. Jones,” Smith filed a lawsuit against Jones. The letter “v”
comes from a Latin word, and in court cases, stands for the word “against.” So “Smith v. Jones” means Smith
against Jones.
The person who filed the lawsuit and is doing the suing is called the Plaintiff; the person who is being sued is
called the Defendant. In the case of Smith v. Jones, Smith is the Plaintiff and Jones is the Defendant.
Docket Number
The docket number is the number used by the Court to identify your case. If you do not know the docket
number, ask the clerk. You should only leave this box blank if the case has not been filed yet. That is the only
time the case will not already have a docket number.
Judicial District
For family court cases, the state is divided into Judicial Districts. Put the name of the Judicial District where
your case is.
Name of applicant
Put in the name of the person who is:
(1) asking the court to not have to pay certain fees, or
(2) asking the court to pay certain fees for them, or
(3) asking the court to appoint an attorney to represent them.
Type of proceeding
Check the box for the type of case this is.
Contempt
Contempt is not obeying a court order on purpose.
Motion to Open or Modify
Asking the court to review or change an order.
Paternity
Deciding who the legal father of a child is.
Application for Custody
Asking the court for orders involving custody of a child or children.
Print Form
JD-FM-75H Rev. 1-19
Application or Petition for Visitation
Asking the court for orders involving visitation rights with a child or children.
Other (Specify)
If this application is for a type of case or proceeding that is not included in the list, put the type of case or
proceeding it is here.
Fee Waiver/Payment of Costs
Check the boxes for the fees that you are asking the court to waive or the costs you are asking the State to
pay.
Grounds for Appeal
Only fill in this section if you are trying to bring your case in the Appellate or Supreme Court. Fill in the legal
reason for your appeal.
Appointment of Counsel
Check this box to ask the court to appoint an attorney to represent you. In family cases, you can only ask the
court to appoint an attorney for you if you are accused of not obeying a court order (contempt) or if the case is
to decide if you are the father of a child (paternity).
Putative father
The person someone says is the father of a child.
Financial Affidavit
An affidavit is a written statement that you swear is true.
Dependents
A dependent is another person who is supported by you; for example, a child.
Gross monthly income (before deductions)
In this box, put the total amount you get paid each month before any amounts are taken from your pay.
Net monthly income after taxes from monthly employment
This is the amount you get paid after amounts are taken from your pay, including federal tax, state tax, social
security taxes, Medicare taxes, and other similar amounts taken from your pay.
Total Monthly Income (B+C)
Add the amount in the "Net monthly income after taxes from monthly employment" box to the amount in the
"Other Income" box and put the total here. If you put nothing (or 0), you have to explain why at the top of the
next page.
Total Monthly Expenses
Add the amounts in boxes A, B, C, D, E, F, G, H, I and J in this section and put the total here. If you put
nothing (or 0), you have to explain why at the top of the next page.
Print Form
JD-FM-75H Rev. 1-19
Assets
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).
Equity
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.
Other Assets
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.
Total Assets
Add the amounts in boxes A, B, C, D, E, F and G in this section and put the total here.
Liabilities/Debts
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.
Total Liabilities
Add up the amounts in these columns and put the total here.
Certify
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.”
Signed (Applicant)
Do not sign this form until you are with a notary public, a court clerk or an attorney and they agree to sign it
with you.
Order
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.
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HELP TEXT FOR APPLICATION FOR WAIVER OF FEESPAYMENT (State of ConnecticutDepartment of Administrative Services)

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Completed 30 July 2021

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