Application & Declaration Form For Deferral Or Waiver Of Fees Page 4
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5_____________________________ _______ $_______ $_______ $_______ ______
_
8. ALL OTHER PROPERTY OR ASSETS (such as: ATVs, RVs, boats, guns, jewelry, livestock, etc.):
Description
Value
Description
Value
______________________ $______
______________________ $______
______________________ $______
______________________ $______
______________________ $______
______________________ $______
9. LIQUIDATION OF ASSETS
:
If you are unable to sell or liquidate your assets, explain why
__________________________________________________________________
__________________________________________________________________
10. MONEY OWED TO YOU BY OTHERS (tax refunds, judgments, trust funds, settlements, etc.):
Name of Debtor Owing You Money
Amount Owed
Date Expected
____________________________________________ $__________
__________
____________________________________________ $__________
__________
11. ARE YOU SEEKING TEMPORARY CHILD AND/OR SPOUSAL SUPPORT?
No
Yes (How much? $_____________
12. OTHER INFORMATION YOU WANT COURT TO CONSIDER
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Do you have a lawyer (or do you plan to) to represent you in this case?
Yes
No
Have you paid your lawyer money?
No
Yes (How much? $_____________ )
Do you have a contingency fee agreement with your lawyer?
No
Yes
Certificate of Document Preparation. Check all that apply:
I chose this form for myself and completed it without paid help.
A legal help organization helped me choose or complete this form, but I did not pay money to anyone.
I paid (or will pay)
for help choosing, completing, or reviewing this form.
TurboCourt selected and completed this form and I did not pay anyone to review the completed form
I hereby declare that the above statements are true to the best of my knowledge
and belief, and that I understand they are made for use as evidence in court and I
am subject to penalty for perjury.
__________
__________________________________________
Date
Signature of Applicant
(
Plaintiff/Petitioner
Defendant/Respondent)
__________________________________________
Name of Applicant (printed or typed)
Fee Deferral or Waiver Application and Declaration (eForm: 11/9/12)
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