Fw 001 Application For Waiver Of Court Fees And Costs Page 2

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FW-001
PLAINTIFF/PETITIONER:
CASE NUMBER:
DEFENDANT/RESPONDENT:
FINANCIAL INFORMATION
10. c.
8.
My pay changes considerably from month to month. [If you
Cars, other vehicles, and boats (list make, year, fair
market value (FMV), and loan balance of each):
check this box, each of the amounts reported in item 9
should be your average for the past 12 months.]
Property
FMV
Loan Balance
9. MY MONTHLY INCOME
(1)
$
$
a. My gross monthly pay is:
. . . . . . . . . . . . .
(2)
$
$
$
b. My payroll deductions are (specify
(3)
$
$
purpose and amount):
d. Real estate (list address, estimated fair market value
(FMV), and loan balance of each property):
(1)
$
(2)
$
Property
FMV
Loan Balance
(3)
(1)
$
$
$
(4)
(2)
$
$
$
My TOTAL payroll deduction amount is:
(3)
$
$
$
c. My monthly take-home pay is
e. Other personal property — jewelry, furniture, furs, stocks,
bonds, etc. (list separately):
(a. minus b.):
. . . . . . . . . . . . . . . . . . . . . .
$
d.
Other money I get each month is (specify source and
amount; include spousal support, child support, paren-
$
tal support, support from outside the home, scholar-
11. My monthly expenses not already listed in item 9b above
ships, retirement or pensions, social security, disability,
are the following:
unemployment, military basic allowance for quarters
a. Rent or house payment & maintenance
$
(BAQ), veterans payments, dividends, interest or royalty,
b. Food and household supplies
. . . . . . . . .
$
trust income, annuities, net business income, net rental
c. Utilities and telephone
. . . . . . . . . . . . . . .
income, reimbursement of job-related expenses, and net
$
gambling or lottery winnings):
. . . . . . . . . . . . . . . . . . . . . . . . . .
d. Clothing
$
(1)
e. Laundry and cleaning
. . . . . . . . . . . . . .
$
$
. . . . . . . .
(2)
f.
Medical and dental payments
$
$
(3)
$
g. Insurance (life, health, accident, etc.)
$
h. School, child care
. . . . . . . . . . . . . . . . .
(4)
$
$
$
i.
Child, spousal support (prior marriage)
The TOTAL amount of other money is:
$
(If more space is needed, attach page
j.
Transportation and auto expenses
labeled Attachment 9d.)
(insurance, gas, repair)
. . . . . . . . . . . . .
$
k. Installment payments (specify purpose and amount):
e. MY TOTAL MONTHLY INCOME IS
(c. plus d.):
. . . . . . . . . . . . . . . . . . . . . . . .
(1)
$
$
f.
Number of persons living in my home:
(2)
$
Below list all the persons living in your home, including
(3)
$
your spouse, who depend in whole or in part on you for
The TOTAL amount of monthly
support, or on whom you depend in whole or in part for
installment payments is:
. . . . . . . . . . . . .
$
support:
Gross Monthly
l. Amounts deducted due to wage assign-
Name
Age
Relationship
Income
ments and earnings withholding orders:
$
(1)
$
m. Other expenses (specify):
(2)
$
(1)
$
$
(3)
(2)
$
$
(4)
(3)
$
(5)
$
(4)
$
The TOTAL amount of other money is:
$
(5)
$
(If more space is needed, attach page
The TOTAL amount of other monthly
labeled Attachment 9f.)
expenses is:
. . . . . . . . . . . . . . . . . . . . . .
$
g. MY TOTAL GROSS MONTHLY HOUSEHOLD INCOME IS
n. MY TOTAL MONTHLY EXPENSES ARE
. . . . . . . . . . . . . . . . .
(a. plus d. plus f):
$
(add a. through m.):
. . . . . . . . . . . . . . . .
$
10. I own or have an interest in the following property:
12. Other facts that support this application are (describe un-
. . . . . . . . . . . . . . . . . . . . . . . . . .
a. Cash
$
usual medical needs, expenses for recent family emergen-
b. Checking, savings, and credit union accounts (list banks):
cies, or other unusual circumstances or expenses to help the
(1)
$
court understand your budget; if more space is needed,
(2)
$
attach page labeled Attachment 12):
(3)
$
(4)
$
WARNING: You must immediately tell the court if you become able to pay court fees or costs during this action. You may
be ordered to appear in court and answer questions about your ability to pay court fees or costs.
APPLICATION FOR WAIVER OF COURT FEES AND COSTS
FW-001 (Rev. January 1, 2007]
Page 2 of 2
(Fee Waiver)
For your protection and privacy, please press the Clear This
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Clear This Form
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