IN THETRIBAL COURT OF THE

QUECHAN INDIAN TRIBE

450 Quechan Drive, Winterhaven, CA92283

Petitioner’s Name and Address
______/ Respondent’s Name and Address
______/ ______
Case Number
APPLICATION FOR WAIVER OF COURT FEES

The following proceeding or action occurred on the below stated date in the Tribal Court.

X Review of Financial Waiver Request

The Court Found and Ordered

□ Approved Waiver

□ Approved Waiver for the following ______%

□ Denied Waiver for the following reasons:

______

Dated this ______day of ______, 20______.

______

Judge of the Tribal Court

Cc: Petitioner

______Case Number: ______

Name of Petitioner/Plaintiff Financial Statement Questioner Request

The Tribal Court needs to know about your financial situation to determine whether you are eligible for waived filing fees. Answer the questions carefully; you could face punishment for prosecution and perjury. I swear or affirm that the information in this application is true and correct. I make this statement under the penalty or prosecution for perjury if it is determined that I did not tell the truth.

Financial Statement:

Assistance: Receiving assistance for:

  1. Health Care: _____ Name: ______
  2. Food Stamps: _____
  3. Commodities: ______
  4. Other: ______
  5. State received in ______

Monthly Income:

1. What is your monthly income? ______

Include: Land lease, Spousal income, Employment, Social services, General assistance.

2. Source of income ______

3. Do you have bank accounts? ______If yes, what is the balance in the accounts.

Checking: ______Savings: ______Other: ______

Total of all accounts: ______

3. Are you employed? Yes _____ No _____

If yes, Employer’s Name: ______

4. Do you own your home? _____ If yes, what is the value $______

5. Do you rent? _____ If yes, what is your monthly payment: $______

  1. How many in the household? ______Names and Ages of Those in the Household: ______

7. What is your social security number? ______

8. Are there any existing hardships? ______

______

9. Is there any other information that you would like the Court to know?

______

I authorize the Tribal Court to investigate the above statements. The information on this form will become public filing.

The undersigned swears or affirms that the statements set forth above are true, correct, and complete to the best of my knowledge and are subject to penalties of making a false affidavit or declaration.

Date: ______

Petitioner

Subscribed and sworn to before me on this ______day of ______, 20______.

______

My Commission ExpiresNotary Public/Court Clerk

QUECHAN TRIBAL COURT

WAIVER OF FILING FEE GUIDELINES

1.Fees In accordance with Quechan Law and Order Code §5.1.4., fees are set by the Chief Judge. The Chief Judge may waive all or part of the filing fee upon the plaintiff/petitioner’s showing of undue hardship. A Waiver of Fee Application must be completed.

Petition for Annulment$100.00

Petition for Dissolution of Marriage (Divorce)$100.00

Petition for Legal Separation$100.00

All Other Petitions and Applications (Except)$ 25.00

Petition to Enforce Court Order N/C

2.Purposes

  1. To establish a standard of income eligibility for petitioners consistent with the ability to pay.
  2. To make payment of fees consistent for persons in similar circumstances.
  3. To give petitioners and the court guidance in the granting of a waiver of fees.

3.Premises

A.Only enrolled members of the Quechan Indian Tribe, their spouses, parents, and children are eligible for a waiver of fee.

B.The income eligibility guidelines are based upon the 2007 HHS Poverty Guidelines and the 2007 WIC Income Guidelines.

C.The court may deviate from the guidelines based upon individual circumstances as indicated on the Application for Waiver of Court Fees.

4.Chart

Column A / Column B / Column C / Column D
Persons In Family or Household / Monthly Under / Monthly Income At Least
But Not Greater Than / Monthly Income
Greater Than
1 / $ 850 / $ 851 – 1,575 / $ 1,576
2 / 1,140 / 1,141 – 2,111 / 2,112
3 / 1,430 / 1,431 – 2,648 / 2,648
4 / 1,720 / 1,721 – 3,184 / 3,185
5 / 2,010 / 2,010 – 3,721 / 3,722
6 / 2,300 / 2,301 – 4,257 / 4,258
7 / 2,590 / 2,591 – 4,794 / 4,795
8 / 2,880 / 2,881 – 5,330 / 5,331
For each additional person add / 290 / 537 / 537

5.Waiver

A.If income falls within Column B, 100% of fee waived

B.If income falls within Column C, 80% of fee waived

C.If income falls within Column D, no waiver of fee granted

Revised: 8/27/2009Page 1 of 4

Form M17