Form JD-FM-6-SHORT "Financial Affidavit" - Connecticut

What Is Form JD-FM-6-SHORT?

This is a legal form that was released by the Connecticut Superior Court - a government authority operating within Connecticut. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on February 1, 2016;
  • The latest edition provided by the Connecticut Superior Court;
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Download Form JD-FM-6-SHORT "Financial Affidavit" - Connecticut

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FINANCIAL AFFIDAVIT
STATE OF CONNECTICUT
Court Use Only
*FINAFFS*
SUPERIOR COURT
JD-FM-6-SHORT Rev. 2-16
FINAFFS
P.B. §§ 25-30, 25a-15
www.jud.ct.gov
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the
Instructions
Americans with Disabilities Act (ADA). If you need a reasonable
Use this short version if your gross annual income is less than $75,000 (see Section I.
accommodation in accordance with the ADA, contact a court
clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
Income) and your total net assets are less than $75,000 (see Section IV. Assets).
Docket number
Otherwise, use the long version, form JD-FM-6-LONG.
- FA -
-
- S
For the Judicial District of
At (Address of Court)
Name of case
Name of affiant (Person submitting this form)
Plaintiff
Defendant
Certification
I understand that the information stated on this Financial Statement and the attached Schedules, if any, is complete, true, and
accurate. I understand that willful misrepresentation of any of the information provided will subject me to sanctions
and may result in criminal charges being filed against me.
I. Income
1) Gross Weekly Income/Monies and Benefits From All Sources
Computed based on year-to-date, but no less than the last 13 weeks. If computation is based on less than 13 weeks or if
your computations are not reflective of current wages, explain:
Paid:
Weekly
Bi-weekly
Monthly
Semi-monthly
Annually
If income is not paid weekly, adjust the rate of pay to weekly as follows:
Bi-weekly → divide by 2
Semi-monthly → multiply by 2, multiply by 12, divide by 52
Monthly → multiply by 12, divide by 52
Annually → divide by 52
(a)
Employer
Address
Base Pay:
Salary
Wages
Job 1
$
Salary
Wages
Job 2
$
Salary
Wages
Job 3
$
Total of base pay from salary and wages of all jobs............................................................................ $
(b) Overtime .............................................. $
(j) Child Support (Actually received)............ $
(c) Self-employment ................................... $
(k) Alimony (Actually received) .................... $
(d) Tips...................................................... $
(l) Rental and income producing property.... $
(e) Social Security ...................................... $
(m) Contributions from household member(s) $
(f) Disability............................................... $
(n) Cash income ......................................... $
(g) Unemployment ..................................... $
(o) Veterans Benefits .................................. $
(h) Worker's compensation ......................... $
(p) Other:
$
(i) Public Assistance (Welfare, TFA
payments) ............................................ $
(q) Total Gross Weekly Income/Monies and Benefits From All Sources (Add items a through p)
$
Hours worked per week
Gross yearly income from prior tax year. Provide amount of income, not copies of forms ............................... $
List here and explain any other income including but not limited to: non-reported income; and support provided by relatives,
friends, and others:
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Click here to get more information about the fields on this form.
FINANCIAL AFFIDAVIT
STATE OF CONNECTICUT
Court Use Only
*FINAFFS*
SUPERIOR COURT
JD-FM-6-SHORT Rev. 2-16
FINAFFS
P.B. §§ 25-30, 25a-15
www.jud.ct.gov
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the
Instructions
Americans with Disabilities Act (ADA). If you need a reasonable
Use this short version if your gross annual income is less than $75,000 (see Section I.
accommodation in accordance with the ADA, contact a court
clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
Income) and your total net assets are less than $75,000 (see Section IV. Assets).
Docket number
Otherwise, use the long version, form JD-FM-6-LONG.
- FA -
-
- S
For the Judicial District of
At (Address of Court)
Name of case
Name of affiant (Person submitting this form)
Plaintiff
Defendant
Certification
I understand that the information stated on this Financial Statement and the attached Schedules, if any, is complete, true, and
accurate. I understand that willful misrepresentation of any of the information provided will subject me to sanctions
and may result in criminal charges being filed against me.
I. Income
1) Gross Weekly Income/Monies and Benefits From All Sources
Computed based on year-to-date, but no less than the last 13 weeks. If computation is based on less than 13 weeks or if
your computations are not reflective of current wages, explain:
Paid:
Weekly
Bi-weekly
Monthly
Semi-monthly
Annually
If income is not paid weekly, adjust the rate of pay to weekly as follows:
Bi-weekly → divide by 2
Semi-monthly → multiply by 2, multiply by 12, divide by 52
Monthly → multiply by 12, divide by 52
Annually → divide by 52
(a)
Employer
Address
Base Pay:
Salary
Wages
Job 1
$
Salary
Wages
Job 2
$
Salary
Wages
Job 3
$
Total of base pay from salary and wages of all jobs............................................................................ $
(b) Overtime .............................................. $
(j) Child Support (Actually received)............ $
(c) Self-employment ................................... $
(k) Alimony (Actually received) .................... $
(d) Tips...................................................... $
(l) Rental and income producing property.... $
(e) Social Security ...................................... $
(m) Contributions from household member(s) $
(f) Disability............................................... $
(n) Cash income ......................................... $
(g) Unemployment ..................................... $
(o) Veterans Benefits .................................. $
(h) Worker's compensation ......................... $
(p) Other:
$
(i) Public Assistance (Welfare, TFA
payments) ............................................ $
(q) Total Gross Weekly Income/Monies and Benefits From All Sources (Add items a through p)
$
Hours worked per week
Gross yearly income from prior tax year. Provide amount of income, not copies of forms ............................... $
List here and explain any other income including but not limited to: non-reported income; and support provided by relatives,
friends, and others:
(Page 1 of 4)
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2) Mandatory Deductions (If consistent deductions don't occur every pay check provide average amounts.)
Job 1
Job 2
Job 3
Totals
$
$
$
$
(1) Federal income tax deductions
(claiming
exemptions)
(2) Social Security or Mandatory Retirement
$
$
$
$
(3) State income tax deductions
$
$
$
$
(claiming
exemptions)
(4) Medicare
$
$
$
$
(5) Health insurance
$
$
$
$
(6) Union dues
$
$
$
$
(7) Prior court order — child support or alimony
$
$
$
$
(8) Total Mandatory Deductions
$
$
$
$
(add items 1 through 7)
3) Net Weekly Income.............................................................................................................................. $
Subtract the Total Mandatory Deductions [see item I., 2), (8)] from the Total Gross Weekly Income/Monies and Benefits
From All Sources [see item I., 1), q) ]
II. Weekly Expenses Not Deducted From Pay
If expenses are not paid weekly, adjust the rate of payment to weekly as follows:
Bi-weekly → divide by 2
Semi-monthly → multiply by 2, multiply by 12, divide by 52
Monthly → multiply by 12, divide by 52
Annually → divide by 52
Insert an ("x") in the box if you are not currently paying the expense, or if someone else is paying the expense.
Home:
Rent or Mortgage (Principal, Interest —
$
$
Property taxes and assessments ...........
Real Estate Taxes and Insurance if
escrowed)
Utilities:
Oil ........................................................
$
Telephone/Cell/Internet............................
$
Electricity ..............................................
$
Trash Collection ......................................
$
Gas ......................................................
$
T.V./Internet ............................................
$
Water and Sewer...................................
$
Groceries (after food stamps): Including household supplies, formula, diapers .........................................
$
Transportation:
Gas/Oil .................................................
$
Auto Loan or Lease .................................
$
Repairs/Maintenance .............................
$
Public Transportation...............................
$
Automobile Insurance/Tax/Registration ...
$
Insurance Premiums:
Medical/Dental (Out-of-pocket expense
Life .........................................................
$
$
after Health Savings Account/Plan).......
Uninsured Medical/Dental not paid by insurance ...................................................................................
$
Clothing .............................................................................................................................................
$
Child(ren):
Child Care Expense (after deductions,
Child Support of this case .....................
$
$
credits and subsidies)............................
Child Support of other children other than
Child(ren)'s activities (e.g., lessons, sports,
$
$
this case (attach a copy of the order) ...
etc.) .....................................................
Alimony: Payable to this spouse ...............
$
Alimony: Payable to another spouse .......
$
Extraordinary travel expenses for visitation with child(ren) ........................................................................
$
Other (Specify):
$
Total Weekly Expenses Not Deducted From Pay ................................................................................... $
III. Liabilities (Debts)
Do not include expenses listed above. Do not include mortgage current principal balance or loan balances that are listed
under “Assets.”
Date Debt
Weekly
Creditor Name /Type of Debt
Balance Due
Incurred/
Payment
Revolving
Credit Card, Consumer, Tax, Health Care, Other Debt
Sole
Joint $
$
Sole
Joint $
$
JD-FM-6-SHORT
Rev. 2-16
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Sole
Joint $
$
Sole
Joint $
$
Sole
Joint $
$
(A). Total Liabilities (Total Balance Due on Debts) ................................... $
(B). Total Weekly Liabilities Expense
................................................................................................... $
IV. Assets
Note: Under "Ownership" indicate S for sole, JTS for joint with spouse, and JTO for joint with other.
You must complete the last column to the right "Value of Your Interest" in each applicable section.
A. Real Estate (including time share)
b. Mortgage
c. Equity Line of
Ownership
a. Fair Market
d. Equity
e. Value of Your
Address
Current Principal
Credit and Other
(d = a minus (b + c))
Value (Estimate)
Interest
S
JTS JTO
Balance
Liens
Home
$
$
$
$
$
Other
$
$
$
$
$
$
$
$
$
$
Total Net Value of Real Estate: $
B. Motor Vehicles
Ownership
c. Equity
d. Value of Your
Year
Make
Model
a. Value
b. Loan Balance
(c = a minus b)
Interest
S
JTS
JTO
1:
$
$
$
$
2:
$
$
$
$
Total Net Value of Motor Vehicles: $
C. Bank Accounts
Do not include custodial accounts or child(ren)'s assets — complete Section V. below.
Ownership
Current Balance/
Account Number
Value of Your
Institution
Value
Interest
(last 4 numbers only)
S JTS JTO
Checking
$
$
Savings
$
$
Other
$
$
Total Net Value of Bank Accounts: $
D. Stocks, Bonds, Mutual Funds
Account Number
Current Balance/
Company
Listed Beneficiary
(last 4 numbers only)
Value
$
$
Total Net Value of Stocks, Bonds, Mutual Funds: $
E. Insurance (exclude children) D = Disability
L = Life
Current Balance/
Account Number
Name of Insured
D L
Company
Listed Beneficiary
(last 4 numbers only)
Value
$
$
Total Net Value of Insurance: $
F. Retirement Plans (Pensions on Interest, Individual IRA, 401K, Keogh, etc.)
Account Number
Current Balance/
Receiving
Type of Plan
Name of Plan/Bank/Company
Listed Beneficiary
(last 4 numbers only)
Payments
Value
$
Yes
No
$
Yes
No
Total Net Value of Retirement Plans: $
G. Business Interest/Self-Employment
If you own an interest in a business, or are self-employed, complete this section.
Name of Business
Percent Owned
Value
$
%
Total Net Value of Business Interest/Self-Employment: $
JD-FM-6-SHORT
Rev. 2-16
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H. Other Assets
Current Balance/
Current Balance/
Name of Asset
Name of Asset
Value
Value
$
$
$
$
$
$
$
$
Total Net Value of Other Assets: $
I. Total Net Value All Assets (add items A through H)...............................................................................
$
V. Child(ren)'s Assets
Include Uniform Gift to Minor Account, Uniform Trust to Minor Account, College Accounts/529 Account, Custodial Account,
etc.
Account Number
Person Who Controls the Account
Current Balance/
Institution
Listed Beneficiary
Value
(last 4 numbers only)
(Fiduciary)
$
$
Total Net Value of Child(ren)'s Assets: $
VI. Health
(Medical and/or Dental Insurance)
Company
Name of Insured Person(s) Covered by the Policy
Do you or any member of your family have HUSKY Health Insurance Coverage?
Yes
No
I Don't Know
If Yes, whom?
Important:
If you have other financial information that has not yet been disclosed, you have an affirmative duty to disclose that
information. List additional information below:
Summary
(Use the amounts shown in Sections I. through IV.)
Total Net Weekly Income (See Section I. 3) ............................................................................................... $
Total Weekly Expenses and Liabilities (Total From Section II. + III.(B)) ...................................................... $
Total Cash Value of Assets (See Section IV. I.) ......................................................................................... $
Total Liabilities (Total Balance Due on Debts) (See Section III. (A))............................................................. $
Certification
I certify under the penalties of perjury that the information stated on this Financial Statement and the attached Schedules, if
any, is complete, true, and accurate. I understand that willful misrepresentation of any of the information provided will
subject me to sanctions and may result in criminal charges being filed against me.
I,
the
Plaintiff
Defendant herein, residing at
, telephone number
, being duly
sworn, depose and say that the following is an accurate statement of my income from all sources, my liabilities, my assets
and my net worth, from whatever sources, and whatever kind and nature, and wherever situated.
Date signed
Signed (Affiant)
Signed (Notary, Commissioner of Superior Court, Assistant Clerk, Other
Print name and title of person signing at left
Date signed
Proper Officer under Section 1-24 of the Connecticut General Statutes)
JD-FM-6-SHORT
Rev. 2-16
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