Form Jdf 205 - Request To Waive Mediation Fee (Page 2 of 2) in pdf

Form Jdf 205 - Request To Waive Mediation Fee Page 2

MOTION TO FILE WITHOUT PAYMENT AND SUPPORTING FINANCIAL

AFFIDAVIT

General Information

It is important that you accurately complete all sections of this form as appropriate based on your

personal circumstances. If a section does not apply, please write N/A.

Gross Monthly Income. Includes income from all members of the household who contribute monetarily

to the common support of the household.



Income categories to include:

Wages, including tips, salaries, commissions, payments received as an independent contractor for

labor or services, bonuses, dividends, severance pay, pensions, retirement benefits, royalties,

interest/investment earnings, trust income, annuities, capital gains, unemployment benefits, Social

Security Disability (SSD), Social Security Supplemental Income (SSI), Workman’s Compensation

Benefits, and alimony.

Note: Income from roommates should not be considered if such income is not commingled in accounts or

otherwise combined with the applicant’s income in a fashion which would allow the applicant proprietary

rights to the roommate’s income.



Income categories do not include:

TANF payments, food stamps, subsidized housing assistance, veteran’s benefits earned from a

disability, child support payments, or other public assistance programs.

Liquid Assets. Includes cash on hand or in accounts, stocks bonds, certificates of deposit, equity, and

personal property or investments which could readily be converted into cash without jeopardizing the

applicant’s ability to maintain home and employment.

Expenses. Nonessential items such as cable television, club memberships, entertainment, dining out,

alcohol, cigarettes, etc., shall not be included. Allowable expense categories are listed on JDF 205.

JDF 205

R11/06

MOTION TO: FILE WITHOUT PAYMENT OF FILING FEE/APPOINT AND PAY INTERPRETER AND SUPPORTING FINANCIAL AFFIDAVIT

Form Jdf 205 - Request To Waive Mediation Fee Page 2