Form Jd-Fm-178 (Rev. 11-11) - Affidavit Concerning Military Service

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Court Use Only
JD-FM-178 Rev. 11-11
P.B. § 17-21
Anyone who knows the military status of the defendant may complete the form below. You must swear that
your statement is true and sign it in front of a court clerk, a notary public, or an attorney who will also sign
and date the affidavit. Make one copy for yourself and give the original to the court clerk.
Explanation: A military service affidavit is required in every case where the defendant has not filed an
Appearance form with the court clerk's office by the time of the court hearing. The purpose is to protect men
and women serving in the U.S. military from getting a court judgment against them without first receiving
notice of the lawsuit and a chance to defend the case. The affidavit gives the court the necessary facts to
find that the defendant is not in the U.S military.
Judicial District of
At (Town)
Return date (Month, day, year)
Docket number
Plaintiff's name (Last, first, middle initial)
Defendant's name (Last, first, middle initial)
I certify that the following is true (check all that apply and complete):
1. The defendant is in the U.S. Military.
2. The defendant is not in the U.S. Military. I know this because:
the defendant is working at
the defendant currently lives at
the defendant is
years old.
other (state reasons)
3. I do not know whether the defendant is in the U.S. military service.
Print name
Date signed
Signed and sworn to before me (Assistant Clerk/Notary Public/Commissioner of Superior Court) At (Town, State)
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
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