Jd Fm 6 Long Form PDF Details

Are you looking to become a successful entrepreneur or leader in your field? The JD FM 6 Long Form course could be just what you need to get started on the right path. Offered by world-renowned business leader, entrepreneur, and professor Joe Davis, this comprehensive program will provide you with the essential knowledge and skillset required for success in any business venture. From learning how to build a profitable company from scratch to managing complex organizational issues and developing innovative solutions for common problems - the JD FM 6 Long Form has everything you need for personal and professional growth. Read on to learn more about this exceptional program!

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Form NameJd Fm 6 Long Form
Form Length6 pages
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Avg. time to fill out1 min 30 sec
Other nameswhat ct form financial affidavit, ct financial affidavit jd fm 6 long, financial affidavit state of ct, jd fm 6 financial affidavit

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FINANCIAL AFFIDAVIT

STATE OF CONNECTICUT

JD-FM-6-LONG Rev. 2-16

SUPERIOR COURT

P.B. §§ 25-30, 25a-15

www.jud.ct.gov

 

Instructions

Use this long version if either your gross annual income is more than $75,000 (see Section I. Income) or your total net assets are more than $75,000 (see Section IV. Assets), or if both are more than $75,000. Otherwise, use the short version, form JD-FM-6-SHORT.

 

Court Use Only

*FINAFFL*

 

 

 

FINAFFL

 

 

 

 

 

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.

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)

Job 1

Job 2

Job 3

Salary

Salary

Salary

Base Pay:

Wages $

Wages $

Wages $

Total of base pay from salary and wages of all jobs

$

 

(b)

Overtime

$

 

(c)

Self-employment

$

 

(d)

Tips

$

 

(e)

Commissions

$

 

(f)

Bonuses

$

 

(g)

Dividends

$

 

(h)

Interest

$

 

(i)

Trusts

$

 

(j)

Annuities

$

 

(k)

Pensions

$

 

(l)

.............Retirement/Tax Deferred Funds

$

 

......................................(m) Social Security

$

 

(n)

Disability

$

 

(o)

Unemployment

$

 

(p)

..........................Worker's compensation

$

 

(q)

Public Assistance (Welfare, TFA

 

 

$

 

 

payments)

 

 

 

 

(r)

$

 

Child Support (Actually received)

 

(s)

....................Alimony (Actually received)

$

 

(t)

....Rental and income producing property

$

 

(u)

.......................Royalties and other rights

$

 

(v)

Contributions from household member(s)

$

 

.........................................(w) Cash income

$

 

(x)

..................................Veterans Benefits

$

 

(y)

Other:

 

$

 

 

 

 

 

 

(z) Total Gross Weekly Income/Monies and Benefits From All Sources (Add items a through y)

$

 

(Page 1 of 6)

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)

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.) ...........

Dry Cleaning............................................

Alcohol, Smoking Products .......................

Child(ren):

$

 

Clothing

$

 

..........................................Entertainment

$

 

Vacation

$

$

$

Child Support of this case

$

Child(ren)'s Education (elementary,

$

 

Child Care Expense (after deductions,

 

 

secondary, college, occupational)

 

 

 

 

 

 

 

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.”

Creditor Name/Type of Debt

Balance Due

Date Debt

Incurred/

Revolving

Weekly

Payment

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)

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)

Address

Ownership

a. Fair Market

b. Mortgage

c. Equity Line of

d. Equity

e. Value of Your

 

 

Value (Estimate)

Current Principal

Credit and Other

(D = A MINUS (B + C))

Interest

S

JTS

JTO

 

 

 

 

 

Balance

Liens

 

 

Home

$

Other

$

$

$

$

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

$

 

$

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

$

 

$

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Net Value of Real Estate: $

B. Motor Vehicles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year

Make

 

 

 

 

Model

 

 

Ownership

a. Value

 

b. Loan Balance

c. Equity

d. Value of Your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

JTS

JTO

 

(C = A MINUS B)

Interest

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

Institution

Account Number

(last 4 numbers only)

Ownership

Current Balance/

Value of Your

S

JTS

JTO

Value

Interest

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Company

Account Number

 

 

 

 

Listed Beneficiary

Current Balance/

 

 

 

 

 

(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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Insured

 

D

L

 

Company

Account Number

 

 

 

 

Listed Beneficiary

Current Balance/

 

 

(last 4 numbers only)

 

 

 

 

Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

Total Net Value of Insurance: $

JD-FM-6-LONG Rev. 2-16

(Page 4 of 6)

F. Retirement Plans

(Pensions on Interest, Individual IRA, 401K, Keogh, etc.)

 

 

 

 

 

 

 

 

 

 

 

Type of Plan

 

Name of Plan/Bank/Company

Account Number

Listed Beneficiary

Receiving

 

Current Balance/

 

 

 

(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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Institution/Individual

 

 

Account Number

 

Listed Beneficiary

 

Current Balance/

 

 

 

 

(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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Asset

 

Current Balance/

 

Name of Asset

 

 

Current Balance/

 

 

 

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

 

 

 

$

 

Name of Asset

 

 

 

 

 

 

Name of Beneficiary

 

 

 

Current Balance/

 

 

 

 

 

 

 

 

 

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.

Institution

Account Number

 

Listed Beneficiary

Person Who Controls the Account

Current Balance/

(last 4 numbers only)

 

(Fiduciary)

Value

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

$

Total Net Value of Child(ren)'s Assets: $

JD-FM-6-LONG Rev. 2-16

(Page 5 of 6)

VI. Health Insurance (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? If Yes, whom?

Yes

No

I Don't Know

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. J.)

$

 

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

 

, telephone number

Defendant herein, residing at

, 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.

Signed (Affiant)

 

Date signed

 

 

 

Signed (Notary, Commissioner of Superior Court, Assistant Clerk, Other

Print name and title of person signing at left

Date signed

Proper Officer under Sec. 1-24 of the Connecticut General Statutes)

 

 

 

 

 

 

 

 

JD-FM-6-LONG Rev. 2-16

(Page 6 of 6)

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