Filing Fee Waiver Request

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NEW JERSEY JUDICIARY
Plaintiff
FILING FEE WAIVER REQUEST
Based on Inability to Pay
VS.
Defendant
Applicant’s Name:
Docket Number:
Last
First
MI
Home Address:
Home Phone #
Street
Apt No
(
)
City
State
Zip
Number of Dependants
I,
, am over the age of 18 and request no court fee be charged as I am
without funds to pay the fee. I am a (check one)
Plaintiff
Defendant in the following court:
Civil
Special Civil Part
General Equity
Probate
Family
The following are facts about my financial condition. My income before taxes is:
Salary (per month): $
Other Income (per month): $
Specify source of other income, including six months of prisoners’ account statements in accordance with
N.J.S.A. 30:4-16.3 (per month):
The following is a complete list of everything I own and owe, as far as I know:
Own
Amount $
Owe (per month)
Amount $
Money in any bank accounts
Rent/mortgage
Automobiles
Food
Real estate
Utilities
Insurance with cash value
Alimony/child support
Money owed to me
Auto payment
Other (specify)
Other (specify)
TOTALS
0.00
TOTALS
0.00
Please attach documents as to income (pay stubs, welfare documents, unemployment documents, last bank
statement, etc.)
I certify the statements made by me in this document are true and that my proposed pleading is attached. I
understand that if I give any false information, I may be punished by the court.
I am signing this statement to explain to the court why I am unable to pay any court fees in this lawsuit.
(Rule 1:13-2(a))
Fee Waived:
Yes
No
Signature (Applicant)
Date
Signature (Judge)
Date
(Print Name)
(Print Name)
Revised: 08/05/2010, CN 11208

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