Exemption Of Payment Request printable pdf download

Exemption Of Payment Request

NO. _________________________

PETITIONER:

IN THE DISTRICT COURT

JUDICIAL DISTRICT

DEFENDANT:

{COUNTY, STATE}

REQUEST FOR EXEMPTION FROM PAYMENT OF FEES AND ORDER

I, the Petitioner/Defendant, request an exemption from the payment of the

fee, due to my inability to pay.

Income

Most Recent Employer:

Position Title:

Employment Address:

Phone Number:

Wages:

Income from Other Sources:

Spousal Wages:

Total Income In Past Year:

Spousal Income:

Dependents

Full Name

DOB

Address (if different)

Relationship

Type

Assets Description

Value

Owner

Liabilities

Type

Amount

Mortgage

Car Loan

Business Loan

Student Loan

I swear that the above financial statement is true and correct to the best of my knowledge. I understand

that if I have knowingly falsified the aforementioned information I will be prosecuted for perjury.

PETITIONER SIGNATURE

Subscribed and sworn to before me this

day of

(Notary Public),

County.

My commission expires

Exemption Of Payment Request