SUPPLEMENTAL AFFIDAVIT AND
REQUEST FOR ORDERS
OF MAINTENANCE
JD-FM-233 New 1-15
P.A. 14-217 § 120
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
Name of Applicant (Last, first, middle initial)
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
My spouse or a person I have a civil union with
B. REQUESTS FOR EX PARTE RELIEF (May also be ordered at the time of the hearing)
No other orders exist.
CT40
An order is necessary to maintain my safety or the safety of any dependent child(ren) in common.
CT41
An order is necessary to my basic needs or the basic needs of any dependent child(ren) in common.
CT42
An automobile (specify)
A checkbook (specify)
Documentation of health, automobile or homeowner's insurance (specify)
A document for the purpose of proving my identity (specify)
A key to (specify)
The following personal effects (specify)
CT43
CT44
CT45
CT46
CT47
CT48
C. REQUESTS FOR RELIEF AT THE TIME OF THE HEARING
Make rent or mortgage payments on the family dwelling or the dwelling in which I reside with any dependent child(ren) the respondent
and I have in common.
Maintain utility services or any other necessary services related to the family dwelling or the dwelling in which I reside with any dependent
child(ren) that the respondent and I have in common.
Maintain all existing health, automobile or homeowner's insurance coverage without change in coverage or beneficiary designation.
Provide financial support for the benefit of any dependent child(ren) that the respondent and I have in common provided that the
respondent has a legal duty to support such child(ren) and has the ability to pay.
CT49
CT50
CT51
CT52
Name of Respondent (Last, first, middle initial)
Note to Person Filing Request (Applicant):
This form may only be used if you and the respondent are spouses or if you and
the respondent live together and have a dependent child or children in common.
If you are requesting the court to enter orders to maintain the safety and basic needs of yourself or any dependent child(ren) in your Application for
Relief from Abuse (JD-FM-137), complete Section A, and complete Sections B and C as they apply. If you request any orders in Section C of this
form, those orders cannot enter on an ex parte basis (prior to a hearing) and will be considered when you have a hearing on your application.
Instructions to Person Filing Request (Applicant):
I request that the court enter the following orders because (select all that apply):
Date signed
Subscribed and sworn to before me (Assistant Clerk, Commissioner of Superior Court, Notary Public)
Print name of person signing
Signature
I certify that the statements above are true to the
best of my knowledge and belief.
The respondent is (select all that apply)
Note: If, at your hearing, no order is entered under section B or C, no such order may be entered thereafter pursuant to this section.
Any order entered pursuant to section C shall not be subject to modification. Any order entered pursuant to Sections B and C shall expire at
120 days or sooner as the court may determine after the date of issuance or upon issuance of a superseding order, whichever occurs first.
Any amounts ordered but not paid or collected under this section may be preserved and collectable in an action for dissolution of marriage,
custody, paternity or support.
A. I swear to the following:
An order prohibiting the respondent from:
An order that the respondent provide me with:
An order that the respondent be required to:
A person who is also the parent of my dependent child
or children in common and we all live together
Taking any action that could result in the termination of any necessary utility services or necessary services related to the family dwelling
or dwelling in which I reside.
Taking any action that could result in the cancellation, change of coverage or change of beneficiary of any health, automobile, or
homeowner's policy to the detriment of me or any dependent child(ren) the respondent and I have in common.
Transferring, encumbering, concealing, or disposing of the property specified which is owned or leased by the applicant.
(Specify Below)
*REQMAIN*
REQMAIN
For Court Use Only
