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FINANCIAL AFFIDAVIT

STATE OF CONNECTICUT
SUPERIOR COURT

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

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 For the Judicial District of

*FINAFFL*

FINAFFL

-

-S

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 State