Conn. Practice Book Form 207

The undersigned, on behalf of the Plaintiff/Defendant, propounds the following interrogatories to be

answered by the Defendant/Plaintiff within sixty (60) days of the filing hereof.

(1) For your present residence:

(a) What is the address?

(b) What type of property is it (apartment, condominium, single-family home)?

(c) Who is the owner of the property?

(d) What is your relationship to the owner (landlord, parents, spouse)?

(e) When did you start living at this residence?

(2) List the names of all the adults that live with you.

(a) For each adult you live with, what is your relationship to them (spouse, sibling, roommate, parent,

girlfriend or boyfriend)?

(b) For each adult you live with, what is their financial contribution to the household (who pays the

rent, who pays the utilities, who buys the groceries)?

(3) Give the name and address of your employer.

(a) Are you employed full-time or part-time? Are you self-employed? If you are self-employed, do

not answer (b) through (h) and go directly to Interrogatory #4.

(b) Are you paid a salary, on an hourly basis, or do you work on commission or tips?

(c) What is your income per week?

(d) How many hours per week do you usually work?

(e) Is overtime available, and if it is, how many hours per week do you work overtime and what are

you paid?

(f) Do you receive, or have you ever received, bonus income from your employment and what is the

basis for the bonus?

(g) Does your employer deduct federal and state taxes and Medicare from your wages or are you

responsible for filing your own deductions? If you file, provide a copy of your most recent tax returns.

No.

(Plaintiff)

VS.

(Defendant)

: SUPERIOR COURT

: FAMILY SUPPORT

: MAGISTRATE DIVISION

: JUDICIAL DISTRICT OF

: AT

: (Date)

(h) Do you have a second source of employment? If so, please provide the same information as

requested in (a) through (g).

(4) If you are self-employed:

(a) Are you part of a partnership, corporation or LLC, and if you are, give the name of the business

and your role in it?

(b) Name the other people involved in your business and their roles.

(c) Does the business file taxes (if so, bring copies of the last two tax returns filed to your next

court date)?

(d) Describe the work you do.

(e) How many hours per week do you work, on average?

(f) How much do you typically earn per hour?

(g) List your business expenses, and what they cost per week.

(h) State how you are typically paid (check or cash).

(i) Name the five people or companies you did most of your work for in the last year.

(j) If you have a business account, what bank is it at (bring copies of the last six months of bank

statements to your next court date)?

(k) Do you work alone or do you employ anyone and pay them wages? If you employ anyone, please

identify them, their relationship to you, if any, and the amount you pay them.

(l) How do you keep your payment and expense records? Do you employ an accountant, and if so,

please give the name and address of the accountant responsible for your records?

(5) Except for your current job, list all the places you have worked for in the last three years. For

each place, list the address, the type of work you did, the dates you worked there and how much you

were paid at each job.

(6) If you cannot work because of a disability, what is the nature of your disability?

(a) What is the date you became disabled?

(b) Is this disability permanent or temporary?

(c) If a doctor has told you that you cannot work, what is the name of the doctor and his or her office

(bring a note from this doctor stating that you cannot work to your next court date)?

(d) If a doctor has told you that you cannot work, did he or she say you cannot work full-time or

part-time?

(e) If you have a partial or permanent disability, please provide the percentage rating.

(f) Is your disability the result of an automobile accident, an accident at work, an accident at home

or otherwise? Please give the date and details of the incident and state whether you have filed a

lawsuit or workers’ compensation claim as a result.

(g) Have you had any children since the incident? If so, list their dates of birth.

(7) Have you applied for Social Security Disability (SSD) or Supplemental Security Income (SSI)?

(a) If you did, when did you apply and where are you in the application process?

(b) Have you been told if or when you will receive benefits? If so, who told you and what is the date

they gave you?

(c) If your application for SSD and/or SSI has been denied, did you appeal? If you appealed, what

is the status of the appeal and what lawyer, if any, represents you?

(d) Have you applied for or are you receiving state assistance?

(e) Are you a recipient of the state supplement program, medical assistance program, temporary

family assistance program or state-administered general assistance program (SAGA medical or cash)?

If so, state the source of the benefit, the effective date of the benefit and the date when your eligibility

for benefits will be redetermined by the Department of Social Services.

(8) Do you have any lawsuits pending?

(a) If you do, what type of case is it?

(b) Give the name, address, email address and phone number of the lawyer handling the case for you.

(c) What amount do you expect to recover and when do you expect to receive it?

(d) If you have already settled the case, please provide a copy of the settlement statement.

(9) Do you expect to inherit any money or property in the next six months?

(a) If you do, who do you expect to inherit from and where do they or where did they live?

(b) What do you expect to inherit, what is its value and when do you expect to inherit it?

(c) What is the name and address of the person or lawyer handling the estate and where is the

Probate Court in which the action is filed?

(10) Is anyone holding any money for you? If so, name the person, their relationship to you, their

address and the amount of money they are holding.

(11) Do you own any rental properties, by yourself, with someone else or in trust? If the answer is yes:

(a) Is the property residential or commercial?

(b) Please identify the location of the property or properties, include the address and identify your

ownership interest.

(c) Do you derive any income from the property? Do you calculate your net income from the property

on a weekly, monthly or yearly basis?

(d) What are your expenses relating to the property or properties? Please state the amount of your

mortgage payment, if any, and the amount of your taxes, insurance and utility payments, if any, and

your method of payment of these expenses.

(e) Did you have to apply for a loan to finance any part of the real property or to finance the purchase

of any personal property? If so, identify the item, state the amount of the loan and give a copy of the

loan application.

(12) Are you the beneficiary or settlor of a trust?

(a) If so, please identify the trust, the type of trust, the date of the creation of the trust, the name

and address of the trustee and how the trust is funded.

(b) How often do you receive a distribution from the trust and from whom and in what amounts are

the distributions?

BY _________________________

I, _______________, certify that I have reviewed the interrogatories set out above and the responses

to those interrogatories and that they are true and accurate to the best of my knowledge and belief.

___________________________

Subscribed and sworn to before me this _____________ day of __________, 20____.

____________________________________

Notary Public/

Commissioner of the Superior Court

CERTIFICATION

I certify that a copy of this document was or will immediately be mailed or delivered electronically

or non-electronically on (date) _______ to all attorneys and self-represented parties of record and that

written consent for electronic delivery was received from all attorneys exempt from e-filing and self-represented parties of record who received or will immediately be receiving electronic delivery.

Name and address of each party and attorney that copy was or will immediately be mailed or

delivered to*

*If necessary, attach additional sheet or sheets with the name and address which the copy was or

will immediately be mailed or delivered to.

_________________________________________________________________________________

Signed (Signature of filer) Print or type name of person signing Date Signed

_________________________________________________________________________________

Mailing address (Number, street, town, state and zip code) or Email address, if applicable Telephone number

HISTORY—2026: In the first sentence of the certification, “exempt from e-filing” was added after “from all attorneys.”

COMMENTARY—2026: The changes to this form are consistent with the changes to the proof of service language in Section

10-14 (a).