Indigent Fee Waiver Form - Georgia

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Office of Dispute Resolution
Page 1 of 2
Conasauga Judicial Circuit
Phone: 706-278-5897
P.O. Box 1066
Fax: 706-278-6900
Dalton, Georgia 30722
Indigent Fee Waiver Form
The party requesting a fee waiver/fee reduction for the cost of mediation should complete this form and return it
along with a copy of their most recent Federal tax return to the above address. This form must be received by
the ADR Office ten (10) days prior to the mediation session. Late or incomplete forms will not be accepted. The
requesting party is responsible for notifying the mediator of the results prior to the mediation session.
______________________________________
______________________________________
Name: (Last, First MI)
Civil Action #
______________________________________
______________________________________
Mailing Address
Style of Case (example: Doe vs. Doe)
______________________________________
______________________________________
City, State and Zip
County
______________________________________
______________________________________
Phone
Assigned Judge
I, _____________________________________, personally appeared before the undersigned officer duly authorized
to administer oaths in the State of Georgia, and having been sworn, state the following:
1.
Affiant is a United States citizen above the age of eighteen (18) years, under no legal disability, and has personal
knowledge sufficient to make this affidavit in connection with the above-styled case.
2.
Affiant is the Plaintiff / Defendant (CIRCLE ONE) in the above styled case which has been ordered by the assigned
judge to mediation. Affiant is unable to pay (select one of the following):
____
All of the mediation costs of this action and is therefore requesting a fee waiver.
____
Any of the mediation costs in this action and is therefore requesting a fee reduction.
____
Affiant states that mediation fees can be paid so long as fees do not exceed $______
3.
Affiant provides the following information:
1.
Are you working?
Y / N
Name of Employer: ___________________________
2.
Net Income: _____________________ (Monthly)
3.
List every source and amount of additional income: This includes child support, alimony, welfare, social
security, workman’s comp, unemployment, food stamps, or disability. ____________________________
__________________________________________________________________________________
___________________________________________________________________________________

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