Application For Waiver Of Fees Form
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APPLICATION FOR WAIVER OF
STATE OF CONNECTICUT
FEES/APPOINTMENT OF COUNSEL
SUPERIOR COURT
Instructions to person asking to have the
FAMILY
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fees waived or for appointment of an
JD-FM-75 Rev. 10-13
attorney (applicant)
Instructions to Clerk
C.G.S. §§ 46b-231, 52-259b
1. Print or type all information requested.
1. Bring completed form to a judge or, if
P.B. §§ 8-2, 25-63; P.A. 13-310
2. Sign the Financial Affidavit section in front of
applicable, to a family support magistrate.
a court clerk, a notary public or an attorney.
2. If the application is granted, notify the
This form must be used only for family and family
3. Bring this form to the superior court where your
applicant and counsel, if appointed.
support magistrate matters. For civil, housing and
case will be filed or is pending.
3. If the application for fees payable to the court
small claims matters, use form JD-CV-120.
4. If your application for fees payable to the court
or for costs of service of process is denied,
or for costs of service of process is denied, you
and upon the request of the applicant,
To: The Superior Court
may ask for a hearing on the application.
schedule a hearing on the application.
Name of case
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Docket number (If applicable)
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Judicial District
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Address of court
Name of applicant (Last, first, middle initial)
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Address of applicant (Number, street, town, state and zip)
Telephone (Area code first)
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Contempt
Motion to Open or Modify
Paternity
Type of proceeding
("x" all that apply)
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Dissolution of Marriage (Divorce)
Application for Custody
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Other (Specify):
Dissolution of Civil Union
Application or Petition for Visitation
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Fee Waiver
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)
Entry fee
Costs of service of process
(fee to file case)
(delivery of papers by state marshal or other proper officer)
Filing fee
Costs for participating in parenting education under C.G.S. § 46b-69b
(fee to file motion, etc.)
Other
(For example costs of notice by publication or for a certified copy of judgment, etc.) (Specify):
Appointment of Counsel
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(This applies only in a contempt proceeding or to the putative father in a paternity proceeding.)
I ask that the court appoint an attorney to represent me.
Financial Affidavit
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1. Dependents
4. Assets
(another person who is supported by you)
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Estimated Value
Loan Balance
Equity
Total number of dependents
(not including yourself)
Real Estate
2. Monthly Income
A. Real Estate ........
A. Gross monthly income
(before
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Motor Vehicle
....................................
deductions)
B. Motor Vehicles....
B. Net monthly income after taxes
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Other Property
from monthly employment ...............
C. Other Personal
C. Other income
(for example, TANF,
Property ............
Social Security, child support, alimony,
Savings
(for example, jewelry, furniture, etc.)
etc.) (Specify which one(s) here):
D. Savings Account Balance (Total of all accounts) .......
Checking
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Total Monthly Income (B+C)*
E. Checking Account Balance (Total of all accounts) ......
3. Monthly Expenses
Cash
A. Rent/Mortgage ..............................
F. Cash.................................................................
Other Assets
B. Real Estate Taxes..........................
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G. Other Assets (Specify):
C. Utilities
(telephone, fuel heat, electric,
.......................
water, gas, cable, etc.)
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Total Assets
D. Food
...
(less SNAP (food stamps), if any)
5. Liabilities/Debts
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(for example, credit card balances, loans, etc. Do not
include mortgage or loan balances that are listed under "Assets".)
E. Clothing .......................................
F. Insurance Premiums
(medical/dental,
Monthly
Type of Debt
Amount Owed
...............................
auto, life, home)
Payment
G. Medical/Dental ..............................
H. Transportation
......
(bus, gasoline, etc.)
I. Child Care ....................................
J. Other
(medical, dental, child support paid,
alimony paid, etc.) (Specify):
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Total Monthly Expenses*
Total Liabilities
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* If you claim zero Total Monthly Income or Expenses, explain how you are supported:
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