Page 1 of 3
Total Monthly Expenses
J. Other
(child support, alimony, etc.) (Specify):
1. Dependents (people supported by you)
2. Monthly Income
3. Monthly Expenses
Total number of dependents (not including yourself)
A. Gross monthly income
(before deductions) ..........................
B. Net monthly income
(after taxes) from employment.........
C. Other income (TFA, Social Security,
child support, alimony, etc.) ................
(Specify which one(s) here):
Total Monthly Income (B+C)
A. Rent/Mortgage ..............................
B. Real Estate Taxes..........................
C. Utilities
(telephone, electric, water, gas, cable, etc.)
D. Food, not including SNAP (food stamps)..
E. Clothing .......................................
F. Insurance Premiums
(medical/dental, auto, life, home)........
G. Medical/Dental
(costs not covered by insurance)............
H. Transportation (bus, gasoline, etc.).......
I. Child Care ....................................
Type of Debt
A. Real Estate ........
B. Motor Vehicles....
C. Other Personal
Property............
D. Savings Account Balance (Total of all accounts)........
E. Checking Account Balance (Total of all accounts) ......
F. Cash.................................................................
G. Other Assets (Specify):
Type of proceeding (select all that apply)
APPLICATION FOR WAIVER OF FEES/
PAYMENT OF COSTS/APPOINTMENT
OF COUNSEL - FAMILY
JD-FM-75 Rev. 12-21
C.G.S. §§ 46b-160(d), 46b-231, 52-259b;
P.A. 21-15; P.B. §§ 8-2, 25-63, 63-6
Judicial District
Appointment of Counsel (This applies only in a contempt proceeding or to the putative parent in a parentage proceeding.)
Financial Affidavit
Amount Owed
Monthly
Payment
To: The Superior Court
Instructions to Clerk
1. Bring to a judge or family support magistrate, if applicable.
2. If granted, notify the applicant and counsel, if appointed.
3. If the application for waiver of fees payable to the court or
for payment of costs of service of process is denied, and
upon request, schedule a hearing.
Instructions to applicant (person filing)
1. Print or type all information requested.
2. Sign the Financial Affidavit section in front of
a court clerk, a notary public or an attorney.
3. Bring this form to the superior court where
your case will be filed or is/was pending.
4. If your application for waiver of fees payable to
the court or for payment of costs of service of
process is denied, you may ask for a hearing.
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. (select all that apply)
Total Liabilities
5. Liabilities/Debts (for example, credit card balances, loans, etc.
Do not include mortgage or loan balances that are listed under "Assets".)
Estimated Value Loan Balance Equity
Total Assets
4. Assets
Fee Waiver/Payment of Costs
(for example, jewelry, furniture, etc.)
Name of case (Name of plaintiff v. Name of defendant) Docket number (If applicable)
Address of court
Name of applicant (Last, first, middle initial) Address of applicant (Number, street, town, state and zip code)
Phone number
ContemptMotion to Open Judgment
Other (ex parte custody, etc.) (Specify):
Dissolution of Marriage/Civil Union (Divorce)
Motion for Modification
Application for Custody
Application or Petition for Visitation
Parentage
Entry fee (fee to file a new case)
Filing fee(s) (fee to file motion, etc.)
Costs of service of process (delivery of papers by state marshal or other proper officer)
Other (certified copy of judgment, etc.) (Specify):
I ask that the court appoint an attorney to represent me.
Real Estate
Motor Vehicle
Other Property
Savings
Checking
Cash
Other Assets
Use only for family/family support magistrate matters.
For civil, housing and small claims, use form JD-CV-120.
Costs for participating in parenting education under C.G.S. § 46b-69b
Appellate Matter (Supreme or Appellate Court)
Grounds for Appeal (Complete if requesting waiver of Appellate filing fee/payment of cost of the transcript for appeal.)
The grounds on which I propose to appeal are:
Appellate filing fee (Supreme or Appellate Court) Cost of the transcript for appeal
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
Cross Complaint
+
=