Application For Waiver Of Fees Form Page 2
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1
2I certify that the information on page 1 is true and accurate to the best of my knowledge and that I can, if asked, document all income,
expenses, and liabilities listed on page 1.
?
Any false statement made by you under oath which you do not believe to be
Notice
true and which is intended to mislead a public servant in the performance of
u
his or her official function may be punishable by a fine and/or imprisonment.
?
Signed (Applicant)
?
Print name of person signing at left
Date signed
On (Date)
Signed (Notary Public, Commissioner of the Superior Court, Assistant Clerk)
Subscribed and sworn
to before me:
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Order
The Court, having found the applicant ("X" all that apply):
Not indigent
Indigent and unable to pay
Indigent or unable to pay for parenting education program under C.G.S. § 46b-69b, hereby orders the application:
Granted as follows:
1. The following costs are ordered paid by the State
Costs of service of process not to exceed:
$
Other (Specify):
2. The following fees are waived
Entry fee
Filing fee
Other (Specify):
3.
All costs for participation in a parenting education program shall be covered by the service provider pursuant to C.G.S.
§ 46b-69b, because the applicant is found indigent or unable to pay.
4. Counsel is
Appointed (Name):
Denied. If denied only in part, specify:
The application for waiver of the payment of a fee or fees or the cost of service of process is DENIED because the applicant has
repeatedly filed actions with respect to the same or similar matters, such filings establish an extended pattern of frivolous filings that
have been without merit, the application sought is in connection with an action before the court that is consistent with the applicant's
previous pattern of frivolous filings, and the granting of such application would constitute a flagrant misuse of Judicial Branch
resources.
Counsel is not appointed because the applicant does not face potential incarceration.
By the Court (Print or type name of Judge/Fam. Sup. Magistrate)
On (Date)
Signed (Judge, FSM, Assistant Clerk)
Date signed
Request For Hearing On Denied Application
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The following section applies only to a denial of the application for waiver of fees payable to the court or for the costs of service of process.
It does not apply to applications for fee waiver for parenting education or to appointment of counsel.
I request a court hearing on the application.
u
Signed (Applicant)
Date signed
Hearing to be held at the Court location shown on page 1 on the date and time shown below:
Hearing on (Date)
At (Time)
Room number
Signed (Assistant Clerk)
Order After Hearing
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The Court, having found the applicant
Not indigent
Indigent and unable to pay
hereby orders the application:
Granted as follows:
1. The following costs are ordered paid by the State
Costs of service of process not to exceed
$
Other (Specify):
2. The following fees are waived
Entry fee
Filing fee
Other (Specify):
Denied for the following reason(s):
The application for waiver of the payment of a fee or fees or the cost of service of process is DENIED because the applicant has
repeatedly filed actions with respect to the same or similar matters, such filings establish an extended pattern of frivolous filings that
have been without merit, the application sought is in connection with an action before the court that is consistent with the applicant's
previous pattern of frivolous filings, and the granting of such application would constitute a flagrant misuse of Judicial Branch
resources.
By the Court (Print or type name of Judge/FSM)
On (Date)
Signed (Judge, FSM, Assistant Clerk)
Date signed
JD-FM-75 (back) Rev. 10-13
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