Request For Exemption From Payment Of Fees, And Order
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3IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA
AT
)
)
Plaintiff,
)
vs.
)
)
CASE NO.
)
Defendant.
)
REQUEST FOR EXEMPTION FROM
)
PAYMENT OF FEES, AND ORDER
I,
, request exemption from payment of the following
fees due to my financial inability to pay:
Filing fee for a new action or a motion to modify. Admin. Rule 9(f)(1)
Copy fees (including exemplified, certified and regular copy fees). Admin. Rule 9(f)(1)
Servicemembers Civil Relief Act attorney fees. Admin. Rule 12(e)(2)
FINANCIAL STATEMENT
Within the last year, the court exempted me from paying fees in this case due to my inability
to pay. The fee exemption was granted on or about the following date: ________________.
My financial circumstances have not improved. If you checked this box, skip sections 1
through 5 on this form.
I have not been exempted from paying fees in this case or my financial circumstances have
improved. If you checked this box, fill out all sections on this form.
Phone:
Date of Birth:
Residence Address:
Mailing Address:
E-mail Address:
Present Employer:
(If not now employed, state last employer and date employment ended.)
Employer’s
Employer’s
Address:
Phone:
1.
INCOME INFORMATION (after taxes, but before other deductions):
a.
Income during last 12 months:
You
Your Spouse
Wages ........................................
Public Assistance ........................
Unemployment ............................
Other
(Specify)
TOTAL:
b.
Current monthly income from
all sources:
Page 1 of 3
Adm. R. 9(f)(1), Adm. R. 10;
TF-920 (5/16)(cs)
Adm. R. 12(e)(2); Civil R. 90.3
REQUEST FOR EXEMPTION FROM PAYMENT OF FEES, AND ORDER
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