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

What Is Form JD-FM-6-LONG?

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-LONG "Financial Affidavit" - Connecticut

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FINANCIAL AFFIDAVIT
STATE OF CONNECTICUT
Court Use Only
*FINAFFL*
SUPERIOR COURT
JD-FM-6-LONG
Rev. 2-16
FINAFFL
P.B. §§ 25-30, 25a-15
www.jud.ct.gov
ADA NOTICE
Instructions
The Judicial Branch of the State of Connecticut complies with the
Americans with Disabilities Act (ADA). If you need a reasonable
Use this long version if either your gross annual income is more than $75,000 (see
accommodation in accordance with the ADA, contact a court
Section I. Income) or your total net assets are more than $75,000 (see Section IV. Assets),
clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
or if both are more than $75,000. Otherwise, use the short version, form JD-FM-6-SHORT.
Docket number
- 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(s)
Address(es)
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 .............................................. $
(o) Unemployment ...................................... $
(c) Self-employment ................................... $
(p) Worker's compensation.......................... $
(d) Tips...................................................... $
(q) Public Assistance (Welfare, TFA
payments)............................................. $
(e) Commissions ........................................ $
(f) Bonuses ............................................... $
(r) Child Support (Actually received)............ $
(g) Dividends ............................................. $
(s) Alimony (Actually received) .................... $
(h) Interest................................................. $
(t) Rental and income producing property.... $
(i) Trusts................................................... $
(u) Royalties and other rights....................... $
(j) Annuities .............................................. $
(v) Contributions from household member(s) $
(k) Pensions .............................................. $
(w) Cash income ......................................... $
(l) Retirement/Tax Deferred Funds ............. $
(x) Veterans Benefits .................................. $
(m) Social Security ...................................... $
(y) Other:
$
(n) Disability............................................... $
$
(z) Total Gross Weekly Income/Monies and Benefits From All Sources (Add items a through y)
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FINANCIAL AFFIDAVIT
STATE OF CONNECTICUT
Court Use Only
*FINAFFL*
SUPERIOR COURT
JD-FM-6-LONG
Rev. 2-16
FINAFFL
P.B. §§ 25-30, 25a-15
www.jud.ct.gov
ADA NOTICE
Instructions
The Judicial Branch of the State of Connecticut complies with the
Americans with Disabilities Act (ADA). If you need a reasonable
Use this long version if either your gross annual income is more than $75,000 (see
accommodation in accordance with the ADA, contact a court
Section I. Income) or your total net assets are more than $75,000 (see Section IV. Assets),
clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
or if both are more than $75,000. Otherwise, use the short version, form JD-FM-6-SHORT.
Docket number
- 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(s)
Address(es)
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 .............................................. $
(o) Unemployment ...................................... $
(c) Self-employment ................................... $
(p) Worker's compensation.......................... $
(d) Tips...................................................... $
(q) Public Assistance (Welfare, TFA
payments)............................................. $
(e) Commissions ........................................ $
(f) Bonuses ............................................... $
(r) Child Support (Actually received)............ $
(g) Dividends ............................................. $
(s) Alimony (Actually received) .................... $
(h) Interest................................................. $
(t) Rental and income producing property.... $
(i) Trusts................................................... $
(u) Royalties and other rights....................... $
(j) Annuities .............................................. $
(v) Contributions from household member(s) $
(k) Pensions .............................................. $
(w) Cash income ......................................... $
(l) Retirement/Tax Deferred Funds ............. $
(x) Veterans Benefits .................................. $
(m) Social Security ...................................... $
(y) Other:
$
(n) Disability............................................... $
$
(z) Total Gross Weekly Income/Monies and Benefits From All Sources (Add items a through y)
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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:
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), z) ]
4) Other Deductions
(1) Credit Union Loan .................................. $
$
(5) Health Savings Account(s) or Plan(s)......
(2) Savings ................................................. $
$
(6) Deferred Compensation or 401K ............
(3) Retirement............................................. $
$
(7) Other Pre-Tax Deductions......................
(4) Subsequent Other Order of Court............ $
$
(8) Other Wage Executions .........................
(i.e., child support, alimony)
$
(9) Total Other Deductions (add items 1 through 8) ...............................................................................
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 —
$
$
2nd Mortgage/Home Equity Line of Credit
Real Estate Taxes and Insurance if
or Other Lien
escrowed)
$
Property taxes and assessments ..........
Household Improvements
$
$
Condominium Fees................................
(Specify)
Utilities:
Oil ........................................................
$
Telephone/Cell/Internet............................
$
Electricity ..............................................
$
Trash Collection ......................................
$
Gas ......................................................
$
T.V./Internet ............................................
$
Water and Sewer...................................
$
Groceries (after food stamps): Including household supplies, formula, diapers .........................................
$
(Not including take out meals)
Restaurants (Including take out meals) ..................................................................................................
$
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 ...................................................................................
$
JD-FM-6-LONG Rev. 2-16
(Page 2 of 6)
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Insert an ("x") in the box if you are not currently paying the expense, or if someone else is paying the expense.
Personal Care (e.g., haircuts, etc.) ...........
$
Clothing ..................................................
$
Dry Cleaning............................................
$
Entertainment..........................................
$
Alcohol, Smoking Products .......................
$
Vacation .................................................
$
Child(ren):
Child(ren)'s Education (elementary,
$
Child Support of this case ...................
$
secondary, college, occupational) ..........
Child Care Expense (after deductions,
Child(ren)'s activities (e.g., lessons, sports,
$
$
credits and subsidies) ..........................
etc.) .....................................................
Child Support of other children other than
Child(ren)'s camp ....................................
$
$
this case (attach a copy of the order) ...
Child(ren)'s clothing and footwear.............
$
Check here if any part is court ordered
Education (self)......................................................................................................................................
$
Alimony: Payable to this spouse.............................................................................................................
$
Alimony: Payable to another spouse.......................................................................................................
$
Employment related expenses (which are not reimbursed):
Uniforms .............................................................................................................................................
$
Travel .................................................................................................................................................
$
Required continuing education .............................................................................................................
$
Other (Specify):
$
Charitable Contributions .........................................................................................................................
$
Child(ren)'s allowance ............................................................................................................................
$
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 Debt
Sole
Joint $
$
Sole
Joint $
$
Sole
Joint $
$
Sole
Joint $
$
Sole
Joint $
$
Other Consumer Debt
Sole
Joint $
$
Sole
Joint $
$
Tax Debt
Sole
Joint $
$
Sole
Joint $
$
Health Care Debt
Sole
Joint $
$
Sole
Joint $
$
Other Debt
Sole
Joint $
$
Sole
Joint $
$
Sole
Joint $
$
Sole
Joint $
$
Sole
Joint $
$
Sole
Joint $
$
Sole
Joint $
$
(A). Total Liabilities (Total Balance Due on Debts) ................................... $
(B). Total Weekly Liabilities Expense
................................................................................................... $
JD-FM-6-LONG Rev. 2-16
(Page 3 of 6)
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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:
$
$
$
$
3:
$
$
$
$
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
$
$
$
$
Certificate of Deposit
$
$
Credit Union
$
$
Other Account (i.e., money market, U.S. Savings Bonds, etc.)
$
$
Total Net Value of Bank Accounts: $
D. Stocks, Bonds, Mutual Funds, Bond Funds
Account Number
Current Balance/
Company
Listed Beneficiary
(last 4 numbers only)
Value
Stocks
$
Bonds
$
Mutual Funds
$
Bond Funds
$
Total Net Value of Stocks, Bonds, Mutual Funds, Bond 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: $
JD-FM-6-LONG Rev. 2-16
(Page 4 of 6)
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F. Retirement Plans (Pensions on Interest, Individual IRA, 401K, Keogh, etc.)
Account Number
Receiving
Current Balance/
Type of Plan
Name of Plan/Bank/Company
Listed Beneficiary
(last 4 numbers only)
Payments
Value
$
Yes
No
$
Yes
No
$
Yes
No
$
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: $
H. Institutional Held Assets
Account Number
Current Balance/
Institution/Individual
Listed Beneficiary
(last 4 numbers only)
Value
Annuity
$
Cash in Brokerage
$
Account(s)
$
Funds Held in Escrow
Including Money Held
by Attorney
$
Profit Sharing
$
Total Net Value of Institutional Held Assets: $
I. Other Assets
Current Balance/
Current Balance/
Name of Asset
Name of Asset
Value
Value
Arts and Antiques
$
Firearms
$
Cash on hand
$
Home Furnishings
$
Collections
$
Jewelry
$
Contents of Safe or Safe Deposit Box
$
Money Owed to You
$
Crops/Livestock
$
Tools/Equipment
$
Current Balance/
Name of Asset
Name of Beneficiary
Value
Inheritances
$
Other (specify)
$
$
Total Net Value of Other Assets: $
J. Total Net Value All Assets (add items A through I) ...............................................................................
$
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
(last 4 numbers only)
(Fiduciary)
Value
$
$
$
$
$
Total Net Value of Child(ren)'s Assets: $
JD-FM-6-LONG Rev. 2-16
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