Connecticut > Statewide > Civil
Application For Waiver Of Fees JD-CV-120 - Connecticut
| Application For Waiver Of Fees Form. This is a Connecticut form and can be used in Civil Statewide . |
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APPLICATION FOR WAIVER OF FEES CIVIL, HOUSING, SMALL CLAIMS JD-CV-120 Rev. 9-12 C.G.S. §§ 52-259, 52-259b, 52-259c P.B. § 8-2 STATE OF CONNECTICUT Instructions to person asking to have the fees waived (applicant) 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 pending. 4. If your application for fees payable to the court or for costs of service of process is denied, you may ask for a hearing on the application. SUPERIOR COURT www.jud.ct.gov Instructions to Clerk 1. Bring completed form to a judge. 2. If the application is granted, notify the applicant. 3. If the application for fees payable to the court or for costs of service of process is denied, and upon the request of the applicant, schedule a hearing on the application. Docket number (If applicable) Note - This form will be put in the public file. To: The Superior Court Name of case Geographical Judicial Housing Area District Session Number Name of applicant (Last, first, middle initial) Address of court Small Claims Address of applicant (Number, street, town, state and zip) Telephone (Area code first) Type of proceeding Civil case (Regular docket) Small claims case Summary Process/Landlord-Tenant case Other (Specify): Motion to Open, Set Aside, Modify or Extend Civil Judgment Fee Waiver I ask that the court order that I do not have to pay fees or order the State to pay the fees below. (Check all that apply) Entry fee (Regular docket) Entry fee (Small Claims) Filing fee Service of Process (delivery of papers) Other fee (Specify): Financial Affidavit 1. Dependents Total number of dependents (not including yourself) 4. Assets Estimated Value Loan Balance Equity Real Estate 2. Monthly Income A. Gross monthly income (before deductions) A. Real Estate Motor Vehicle B. Motor Vehicles C. Other Personal Property (for example, jewelry, furniture, etc.) Other Property B. Net monthly income after taxes from monthly employment C. Other income (for example, TANF, Social Security, etc.) (Specify source) Savings D. Savings Account Balance (Total of all accounts) Source: Total Monthly Income (B+C)* Checking E. Checking Account Balance (Total of all accounts) Cash F. Cash 3. Monthly Expenses G. Other Assets (Specify): A. Rent/Mortgage B. Real Estate Taxes C. Utilities (Telephone, heat, electric, water, gas, etc.) Other Assets Total Assets D. Food E. Clothing F. Insurance Premiums (Medical/Dental, Auto, Life, Home) 5. Liabilities/Debts (for example, credit card balances, loans, etc. Do not include mortgage or loan balances that are listed under "Assets".) Type of Debt Amount Owed Monthly Payment G. Medical/Dental H. Transportation (bus, gasoline, etc.) I. Child Care J. Other (Specify): Total Monthly Expenses* *If you claim zero Total Monthly Income or Expenses, explain how you are supported: Total Liabilities Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com I 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 X true and which is intended to mislead a public servant in the performance of his or her official function may be punishable by a fine and/or imprisonment. Signed (Applicant) On (Date) Print name of person signing at left Date signed Subscribed and sworn to before me: Signed (Notary Public, Commissioner of the Superior Court, Assistant Clerk) Order Having reviewed the application, the court finds as follows: 1. The applicant is indigent and unable to pay the following fees which are waived: Entry fee (Regular docket) Entry fee (Small Claims) Filing fee Other fee (Specify): ___________________________________ 2. The applicant is indigent and unable to pay the cost of service. A state marshal's fee not to exceed $ ________ shall be paid by the state. 3. The applicant is indigent but able to pay fees and costs of service and the application is denied. 4. The applicant is not indigent and the application is denied. 5. Other (Specify): ______________________________________________________ By the Court (Print or type name of Judge) On (Date) Signed (Judge, Clerk) Date signed Request For Hearing On Denied Application This section should be filled out only if the court has checked #3 or #4 above and denied the application. I request a court hearing on my application. X 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 (Clerk) Order After Hearing Having reviewed the application, the court finds as follows: 1. The applicant is indigent and unable to pay the following fees which are waived: Entry fee (Regular docket) Entry fee (Small Claims) Filing fee Other fee (Specify): ___________________________________ 2. The applicant is indigent and unable to pay the cost of service. A state marshal's fee not to exceed $ ________ shall be paid by the state. 3. The applicant is indigent but able to pay fees and costs of service and the application is denied. 4. The applicant is not indigent and the application is denied. 5. Other (Specify): ______________________________________________________ By the Court (Print or type name of Judge) On (Date) Signed (Judge, Clerk) Date signed JD-CV-120 Rev. 9-12 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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