Affidavit of Indigency

If an is indigent and is not able to pay the required fees for the given service, this affidavit has to be executed by that affiant.

Extracted Text for Proper Search

Page 1 of 2	
Net income 
$	
Total liability 
$	
Real estate 
$
Motor vehicle 
$
Other 
$
Savings 
$
Checking 
$
Stock value 
$
Bond value 
$
Total assets 
$	
A. Real Estate............................
B. Motor Vehicles ........................
C. Other personal property ............
D. Savings accounts  (Total of all accounts) ........................................................
E. Checking accounts  (Total of all accounts).......................................................
F. Stocks:  Name
G. Bonds: Name	
I.
II.
III. Income (Net income after taxes; include all sources)
.......................................
Public Assistance Received:
(If yes, specify type):
Dependents (Total number of dependents) .....................................................
Assets
AFFIDAVIT OF INDIGENCY — 
FEE WAIVER, CRIMINAL 
JD-AP-48   Rev. 8-15 
C.G.S. §§ 54-56g, 52-259b	
Estimated Value	
STATE OF CONNECTICUT 
SUPERIOR COURT	 
www.jud.ct.gov	
Mortgage Balance	Equity	
Source	Amount of Debt	Balance Due	Weekly Payment	Date	
Affidavit
V.
I certify that the information above is accurate to the best of my knowl\
edge and that I can, if requested, submit 
documentation for all income, assets and liabilities listed above. Liabilities 
(Debts)
IV. 	
Instructions to Person Applying for Waiver: 
Print or type all information and sign affidavit in front of court clerk\
, notary public, or an attorney.  
Instructions to Clerk: 
If application is denied and a hearing is requested, schedule hearing an\
d issue notice of hearing.	
Any false statement you make under oath that you do not believe to be tr\
ue 
and that is intended to mislead a public servant in the performance of h\
is or 
her official function may be punishable by a fine and/or imprisonment.	
Notice: ►	
(Attach relevant records)	
$	$	
$ 	$	
$	$	
Name of case	Docket number	
Specify fee to be waived 
(Copies, transcript, program fee, etc.)	
No	Yes	
Number of dependents	
Signed (Applicant)	Print name of person signed at left	Date signed	
Subscribed and sworn 
to before me:	On (Date)	Signed (Notary Public, Commissioner of Superior Court, Assistant Clerk)	
$	$	$
$	$	$	
$	$	$	
$	$	$	
$	$	$	
If the request is for a transcript or for copies, what will the transcri\
pt or copies be used for?	
ADA NOTICE 
  
The  Judicial  Branch of the  State  of 
Connecticut  complies with the Americans  with 
Disabilities  Act (ADA).  If you  need  a 
reasonable  accommodation  in accordance 
with  the ADA,  contact  a court  clerk or an  ADA 
contact person listed at www.jud.ct.gov/ADA.

Page 2 of 2	
Order of Court
For purposes of determining whether a party is indigent and unable to pa\
y a fee to the court or to pay the cost of service: 
"There shall be a rebuttable presumption that a person is indigent and u\
nable to pay a fee or fees or the cost of service of 
process if (1) such person receives public assistance or (2) such pe\
rson's income after taxes, mandatory wage deductions 
and child care expenses is one hundred twenty-five per cent or less of t\
he federal poverty level. For purposes of this 
subsection, "public assistance" includes, but is not limited to, state-a\
dministered general assistance, temporary family 
assistance, aid to the aged, blind and disabled, supplemental nutrition \
assistance, and Supplemental Security Income."  
Section 52-259b(b) of the Connecticut General Statutes.The Court, having found the applicant
orders the application: Indigent and unable to pay
Not indigent
Granted as follows: 1. The following fees payable to the court are waived.  (specify: ) ___________________________________
2. The following fees are ordered paid by the State:
service of process not to exceed $________________ ( specify amount if limited)
other (specify:) ___________________________________________________
I  request a court hearing on the application for a fee waiver.
Request For Hearing On Fee Waiver Application 	(Only if initially denied without a hearing) 
Denied	
Order Of Court After Hearing
The Court, having found the applicant
orders the application:
Indigent and unable to pay
Not indigent
Granted as follows: 1. The following fees payable to the court are waived.  (specify: ) ___________________________________
2. The following fees are ordered paid by the State:
service of process not to exceed $________________ (  specify amount if limited)
other (specify:) ___________________________________________________
Denied
JD-AP-48 (back/page 2)  Rev. 8-15
By the Court (Print name of Judge)	Signed  (Judge, Assistant Clerk)	Date signed	On (Date)	
Signed (Applicant)	Date signed	
Hearing To 
Be Held At	
Superior Court Judicial District or Geographical Area number	Date of hearing	Time of hearing	Room number	
Address of court (Number, street and town)	Signed  (Assistant Clerk)	
By the court (Print name of Judge)	On (Date)	Signed (Judge, Assistant Clerk)	Date signed	
Denied: 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 patter\
n of frivolous filings, and the granting of such 
application would constitute a flagrant misuse of Judicial Branch resour\
ces.
Denied: 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 r\
esources.