Application & Declaration Form For Deferral Or Waiver Of Fees Page 3

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Source of Income (describe)
Amount How long received? How often?
______________________________________ $_________ ____________ __________
______________________________________ $_________ ____________ __________
______________________________________ $_________ ____________ __________
______________________________________ $_________ ____________ __________
Additional Page Attached
Other Party’s Employment and Income (if known to you)
Currently Employed
Not Currently Employed How long since last employment?
Occupation (job title)
Wages/salary $
per
Hours Per
Week
Monthly Income: $
gross (before tax)
net (after taxes)
4. MONTHLY LIVING EXPENSES (Total: $
)
Home
Rent/mortgage $
Food $
Trash $
Utilities
Electric $
Gas $
Water $
Sewer $
Phone $
Cell $
Cable $
Internet $
Transportation
Vehicle payments $
Insurance $
Gas $
/month
Bus $
Parking $
Other
Credit cards $
Student loans $
Court fines $
Medical $
Child support $
Other
(describe)
(You must show proof of the amount you pay for monthly expenses. See Instructions.)
Any other individuals who help pay your living expenses:
Relationship
Amount
Payment for what?
5. MONEY ON HAND / IN BANK
Cash $____________
Checking Account # ________________ Bank/Credit Union _____________ Balance $ ________
Savings Account # _________________ Bank/Credit Union _____________ Balance $ ________
Other Account # __________________ Institution ___________________ Balance $ ________
6. VEHICLES
Year, Make, and Model
Value
Amount Owed
Payments made to:
________________________________ $__________ $__________ ________________
________________________________ $__________ $__________ ________________
7. REAL ESTATE
Address (include city and state)
Purchase
Purchase
Value
Amount
Payments
Year
Price
Owed
Made to:
_____________________________ _______ $_______ $_______ $_______ ______
_
Fee Deferral or Waiver Application and Declaration (eForm: 11/9/12)
Page 3 of 5
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