Form JD-CV-120 "Application for Waiver of Fees/Payment of Costs - Civil, Housing, Small Claims, and Appellate" - Connecticut

What Is Form JD-CV-120?

This is a legal form that was released by the Connecticut Superior Court - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the Connecticut Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-CV-120 by clicking the link below or browse more documents and templates provided by the Connecticut Superior Court.

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Download Form JD-CV-120 "Application for Waiver of Fees/Payment of Costs - Civil, Housing, Small Claims, and Appellate" - Connecticut

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APPLICATION FOR
STATE OF CONNECTICUT
WAIVER OF FEES/
SUPERIOR COURT
Instructions to person asking for the waiver (applicant)
PAYMENT OF COSTS -
1. Fill out Application. For help, see Help Text for Application for Waiver of
www.jud.ct.gov
CIVIL, HOUSING, SMALL
Fees/Payment of Costs - Civil, Housing, Small Claims, and Appellate
CLAIMS, AND APPELLATE
(form JD-CV-120H).
2. Sign the form under oath in front of a clerk, a notary, or an attorney.
JD-CV-120 Rev. 1-19
Note: This form will be put in
C.G.S. §§ 52-259, 52-259b, 52-259c
3. Bring this form to the court where your case will be filed or is/was
the case file, which may
P.B. §§ 8-2, 63-6
pending.
be available to be viewed
4. If this application for fees payable to the court or for costs of service of
Application
by the public.
process is denied, you may ask for a hearing in the Request for Hearing
To: The Superior Court
on Denied Application section on page 2.
Name of case (Plaintiff v. Defendant)
Docket number (If applicable)
Address of court
Judicial
Housing
District
Session
Name of applicant (Last, first, middle initial)
Address of applicant (Number, street, town, state and zip)
Telephone (Area code first)
Type of proceeding:
Civil case
Small claims case
Housing
(Landlord-Tenant case)
Other
(Specify):
Appellate matter (Supreme or Appellate Court)
Fee Waiver/Payment of costs
I ask that the court order that I do not have to pay fees or to order the State to pay the costs below.
(Check all that apply)
Entry fee
Filing fee
Costs of service of process
Appellate filing fee (Supreme or Appellate Court)
(Delivery of papers)
Cost of the transcript for appeal
Other fee
(Specify):
Grounds for Appeal
(Complete if requesting waiver of Appellate filing fee (Supreme or Appellate Court) and/or payment of cost of the transcript for appeal.)
The grounds on which I propose to appeal are:
Financial Affidavit
Equity
1. Dependents
4. Assets
Estimated Value
Loan Balance
(Estimated Value
(Current worth)
(Amount owed)
Total number of dependents
(Do not count yourself)
minus Loan Balance)
Real Estate
2. Monthly Income
A. Real Estate
A. Gross monthly income from all sources
Motor Vehicle
(Money you get in one month from work and
B. Motor Vehicles
other sources, before taxes)
Other Property
C. Other Personal
B. Net monthly income
from
(after taxes)
Property
employment
Savings
C. Income from sources other than
(For example, jewelry, furniture, etc.)
+
employment
(For example, TFA,
D. Savings Account Balance
(Total of all accounts)
Social Security, etc.)
Checking
List sources of
=
E. Checking Account Balance
(Total of all accounts)
other income:
Cash
Total Monthly Income (B+C) =
F. Cash
3. Monthly Expenses
Other Assets
A. Rent/Mortgage
G. Other Assets
:
(Specify)
B. Real Estate Taxes
Total Assets =
C. Utilities
(Telephone, heat,
electric, water, gas, etc.)
5. Liabilities/Debts
(For example, credit card balances, loans, etc. Do not
D. Food
include mortgage or loan balances that are listed under "Assets".)
E. Clothing
Type of Debt
Amount Owed
Monthly Payment
F. Insurance Premiums
(Medical/dental,
auto, life, home)
G. Medical/Dental
H. Transportation
(Bus, gasoline, etc.)
I. Child Care
J. Other
(Specify):
Total Liabilities =
Total Monthly Expenses =
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APPLICATION FOR
STATE OF CONNECTICUT
WAIVER OF FEES/
SUPERIOR COURT
Instructions to person asking for the waiver (applicant)
PAYMENT OF COSTS -
1. Fill out Application. For help, see Help Text for Application for Waiver of
www.jud.ct.gov
CIVIL, HOUSING, SMALL
Fees/Payment of Costs - Civil, Housing, Small Claims, and Appellate
CLAIMS, AND APPELLATE
(form JD-CV-120H).
2. Sign the form under oath in front of a clerk, a notary, or an attorney.
JD-CV-120 Rev. 1-19
Note: This form will be put in
C.G.S. §§ 52-259, 52-259b, 52-259c
3. Bring this form to the court where your case will be filed or is/was
the case file, which may
P.B. §§ 8-2, 63-6
pending.
be available to be viewed
4. If this application for fees payable to the court or for costs of service of
Application
by the public.
process is denied, you may ask for a hearing in the Request for Hearing
To: The Superior Court
on Denied Application section on page 2.
Name of case (Plaintiff v. Defendant)
Docket number (If applicable)
Address of court
Judicial
Housing
District
Session
Name of applicant (Last, first, middle initial)
Address of applicant (Number, street, town, state and zip)
Telephone (Area code first)
Type of proceeding:
Civil case
Small claims case
Housing
(Landlord-Tenant case)
Other
(Specify):
Appellate matter (Supreme or Appellate Court)
Fee Waiver/Payment of costs
I ask that the court order that I do not have to pay fees or to order the State to pay the costs below.
(Check all that apply)
Entry fee
Filing fee
Costs of service of process
Appellate filing fee (Supreme or Appellate Court)
(Delivery of papers)
Cost of the transcript for appeal
Other fee
(Specify):
Grounds for Appeal
(Complete if requesting waiver of Appellate filing fee (Supreme or Appellate Court) and/or payment of cost of the transcript for appeal.)
The grounds on which I propose to appeal are:
Financial Affidavit
Equity
1. Dependents
4. Assets
Estimated Value
Loan Balance
(Estimated Value
(Current worth)
(Amount owed)
Total number of dependents
(Do not count yourself)
minus Loan Balance)
Real Estate
2. Monthly Income
A. Real Estate
A. Gross monthly income from all sources
Motor Vehicle
(Money you get in one month from work and
B. Motor Vehicles
other sources, before taxes)
Other Property
C. Other Personal
B. Net monthly income
from
(after taxes)
Property
employment
Savings
C. Income from sources other than
(For example, jewelry, furniture, etc.)
+
employment
(For example, TFA,
D. Savings Account Balance
(Total of all accounts)
Social Security, etc.)
Checking
List sources of
=
E. Checking Account Balance
(Total of all accounts)
other income:
Cash
Total Monthly Income (B+C) =
F. Cash
3. Monthly Expenses
Other Assets
A. Rent/Mortgage
G. Other Assets
:
(Specify)
B. Real Estate Taxes
Total Assets =
C. Utilities
(Telephone, heat,
electric, water, gas, etc.)
5. Liabilities/Debts
(For example, credit card balances, loans, etc. Do not
D. Food
include mortgage or loan balances that are listed under "Assets".)
E. Clothing
Type of Debt
Amount Owed
Monthly Payment
F. Insurance Premiums
(Medical/dental,
auto, life, home)
G. Medical/Dental
H. Transportation
(Bus, gasoline, etc.)
I. Child Care
J. Other
(Specify):
Total Liabilities =
Total Monthly Expenses =
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Name of case (Plaintiff v. Defendant)
Docket number (If applicable)
6. If you claim zero Total Monthly Income in number 2 above or zero Total Monthly Expenses in number 3 above, explain how
you are supported:
- Notice -
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.
I certify that the information on this application is true and accurate to the best of my knowledge and that I can, if asked,
document all income, expenses, and liabilities listed on this application.
Print name of person signing at left
Signed (Applicant)
Date signed
On (Date)
Signed (Notary Public, Commissioner of the Superior Court, Assistant Clerk)
Subscribed and sworn
to before me:
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
Filing fee
Appellate filing fee (Supreme or Appellate Court)
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 and unable to pay the cost of the transcript for appeal, which shall be paid by the State in
accordance with Practice Book Section 63-6.
4. The applicant is indigent but able to pay fees, costs of service, and the cost of the transcript for appeal, and the
application is denied.
5. The applicant is not indigent and the application is denied.
6. Denied: the 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 resources.
7. Denied. Other (Specify): _______________________________________________________
By the Court (Print or type name of Judge)
On (Date)
Signed (Judge, Clerk)
Date signed
Request For Hearing On Denied Application
(Fees payable to the court or costs of service of process)
This section should be filled out only if the court has checked #4, 5, 6 or 7 above and denied the application.
u
I request a court hearing on my application.
Signed (Applicant)
Date signed
Hearing
Hearing to be held on (Date)
Location
At (Time)
Signed (Clerk)
JD-CV-120 Rev. 1-19
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Name of case (Plaintiff v. Defendant)
Docket number (If applicable)
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
Filing fee
Appellate filing fee (Supreme or Appellate Court)
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 and unable to pay the cost of the transcript for appeal, which shall be paid by the State in
accordance with Practice Book Section 63-6.
4. The applicant is indigent but able to pay fees, costs of service, and the cost of the transcript for appeal, and the
application is denied.
5. The applicant is not indigent and the application is denied.
6. Denied: the 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 resources.
7. Denied. Other (Specify): _______________________________________________________
By the Court (Print or type name of Judge)
On (Date)
Signed (Judge, Clerk)
Date signed
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.
JD-CV-120 Rev. 1-19
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