Verified Motion for Fee Waiver

Rev. 2-2013
STATE OF INDIANA / ) / IN THE DECATUR SUPERIOR COURT
) SS:
COUNTY OF DECATUR / ) / CAUSE NO. 16D01-______

______, )

)

vs.)

)

______, )

VERIFIED MOTION FOR FEE WAIVER

The Petitioner/Plaintiff requests that the Court waive all costs of this case and allow me to proceed without the pre-payment of any filing fees or other costs.

1. I wish to file this case, and I believe that my case has merit.

1. I cannot pay any of the filing fees or other costs of this case because I do not have sufficient income or financial resources.

1. My household consists of _____ persons (the total number of persons living at your residence).

1. My family’s income is as follows:

Wages (______per hour x ______hours per month) / ______
Unemployment compensation / ______
AFDC / TANF Benefits / ______
SSI / SSD Benefits / ______
Child Support / ______
Other:______/ ______
TOTAL / ______
5. / I have ______in my bank account(s).
6. / My family’s expenses are as follows:
Housing (Rent / Mortgage) / ______
Utilities (Gas, Electric, Water, Phone, etc.) / ______
Food / ______
Child Care / ______
Medical Bills / ______
Transportation / ______
Insurance (car, medical, property) / ______
Child Support / ______
Other:______/ ______
TOTAL / ______

I affirm under the penalties for perjury that the foregoing representations are true.

______

Petitioner/Plaintiff

Rev. 2-2013
STATE OF INDIANA / ) / IN THE DECATUR SUPERIOR COURT
) SS:
COUNTY OF DECATUR / ) / CAUSE NO. 16D01-______

______, )

)

vs.)

)

______, )

ORDER ON FEE WAIVER

The Petitioner/Plaintiff filed a Verified Motion for Fee Waiver. The Court now finds:

_____ The Petitioner/Plaintiff has household income which is below the federal poverty guideline amount, and the Petitioner/Plaintiff has substantially complied with Indiana Code§ 33-37-3-2(a). The Verified Motion for Fee Waiver should be granted.

_____The Petitioner/Plaintiff has household income which is above the federal poverty guideline amount. The Verified Motion for Fee Waiver should be denied.

IT IS THEREFORE ORDERED, ADJUDGED, AND DECREED:

_____ The Petitioner/Plaintiff may file this case without the pre-payment of any fees or costs.

_____The request of the Petitioner/Plaintiff to file this case without the pre-payment of fees or costs is denied. The Petitioner/Plaintiff must pay the filing fee to file this case.

SO ORDERED this ____ day of ______, 201___.

______

Matthew D. Bailey, Judge

Decatur Superior Court

Distribution: Clerk of the Court Petitioner/Plaintiff