Connecticut > Statewide > Juvenile
Application For Appointment Of Counsel And Waiver Of Fees JD-JM-114 - Connecticut
| Application For Appointment Of Counsel And Waiver Of Fees Form. This is a Connecticut form and can be used in Juvenile Statewide . |
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APPLICATION FOR APPOINTMENT OF COUNSEL/WAIVER OF FEES JUVENILE JD-JM-114 Rev. 10-11 C.G.S. §§ 46b-135, 136, 53a-157b, § 52-259b, P.A. 11-51, Sec. 19; P.B. §§ 8-2, 30a-1, 32a-1 To: The Superior Court Name of applicant (Last, first, middle initial) Instructions To 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. Submit this form immediately in person, by mail or fax to the superior court where your case will be filed or is pending. 4. If your application is denied, you may request a hearing on the application. Instructions To Clerk 1. Bring completed form to a judge. 2. If the application is granted, notify the applicant and counsel, if appointed. 3. If the application is denied, and upon the request of the applicant, schedule a hearing on the application. STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov Date of birth Address of applicant (Number, street, town, state and zip) Name of employer Address of employer (Number, street, town, state and zip) Telephone (Area code first) Relationship to child Telephone (Area code first) Mother Name of child Father Legal guardian Date of birth Name of child Other Date of birth Name of child Date of birth Docket number (If applicable) Address of Court Type of proceeding Delinquency Family with service needs Emancipation Neglect, uncared-for, abused petition Termination of parental rights petition Probate appeal Probate transfer Transfer/Reinstatement of guardianship Appeal from Juvenile Court Decision Other (Specify): Appointment of Counsel I ask that the court appoint an attorney to represent me. 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 (fee to file case) Filing fee (fee to file motion, etc.) Costs of service of process (delivery of papers by state marshal or other proper officer) Other (Specify): Financial Affidavit 1. Dependents Number of dependents under 18................................ Number of other dependents .................................... Total number of dependents (not including yourself) ...... A. Real Estate ........ Address: B. Motor Vehicles .... Year/Make: C. Other Personal Property.............. (for example, jewelry, furniture, etc.) D. Savings Account Balance (Total of all accounts) ......... E. Checking Account Balance (Total of all accounts) ........ F. Other Assets (Specify stocks, bonds, trust, cd's): ......... 4. Assets - Applicant Estimated Value Loan Balance Equity 2. Gross Monthly Income and Assistance - Applicant A. Employment ............................................. B. State/City Assistance .................................. C. SSI ....................................................... D. Unemployment Compensation........................ E. Worker's Compensation ............................... F. Social Security .......................................... G. Pension.................................................. H. Child Support ........................................... I. Alimony .................................................. Total Gross Monthly Income ........................... Total Assets .................................................. 5. Liabilities/Debts - Applicant (for example, credit card balances, loans, etc.) (Do not include mortgage or loan balances that are listed under "Assets".) Type of Debt Amount Owed Weekly Payment 3. Gross Monthly Income and Assistance - Totals Other Adult Household Members A. Employment ............................................. Name of employer: B. State/City Assistance .................................. C. SSI ....................................................... D. Unemployment Compensation........................ E. Worker's Compensation ............................... F. Social Security .......................................... G. Pension.................................................. H. Child Support ........................................... I. Alimony .................................................. Total Gross Monthly Income ........................... * Total Gross Monthly Income of all adult members of the household: (Add Total Monthly Income of Applicant and any other adults in the household) Total Liabilities *If you claim zero Total Monthly Income, explain how you are supported: Please attach copy of recent paystub(s) if available. (Page 1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com I certify that the foregoing information is accurate to the best of my knowledge and that I can, if requested, document all income, assets, and liabilities listed on the front/page 1. Any false statement made by you under oath which you do not believe to be 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. Notice X Signed (Applicant) Print name of person signing at left Date signed Subscribed and sworn to before me: On (Date) Signed (Notary Public, Commissioner of the Superior Court, Assistant Clerk) Order The Court, having found the applicant ("x" all that apply) Indigent and unable to pay Granted as follows: 1. Counsel is Appointed Appointed in the interests of justice pursuant to Connecticut General Statutes Section 46b-136. The applicant is ordered to reimburse the Public Defender Services Commission at its approved rate for the costs of providing an attorney and said costs shall be payable upon receipt of an invoice from the Public Defender Services Commission. Entry fee 2. The following fees are waived (including additional $5.00, if required) 3. The following fees are ordered paid by the State Other (Specify:) Denied. By the Court (Print or type name of Judge) On (Date) Not indigent and able to pay hereby orders the application: Filing fee Other (Specify:) Marshal's fee not to exceed $ Signed (Judge, Ass't Clerk) Date signed JD-JM-114 (back) Rev. 10-11 (Page 2 of 2) American LegalNet, Inc. www.FormsWorkFlow.com
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