Form Cv-410a - Petition For Waiver Of Fees And Costs - Affidavit Of Indigency printable pdf download

STATE OF WISCONSIN, CIRCUIT COURT,

COUNTY

Amended

Kho ntxiv

Petition for Waiver of

Fees and Costs -

-vs- - xub nrog -

Affidavit of Indigency

Ua Ntawv Thov kom Txhob

Yuav Nqi Tes thiab Nqi

Ntawv -

Ntawv Teev Txoj Kev Txom

Nyem

Case No.Tus Lej Cim

This form does not replace the need for an interpreter, any colloquies mandated by law, or the responsibility of the court and

counsel to ensure that persons with limited English proficiency fully comprehend their rights and obligations.

Tsab ntawv no hloov tsis tau tus neeg txhais lus, txawm hais tias muaj kev sib tham txog dab tsi raws li txoj cai, lossis yog lub

luag haujlwm ntawm lub tsev hais plaub thiab tus kws lij choj kom tus neeg uas tsis txawj lus Meskas muaj kev nkag siab txog

nws cov kev cai thiab nws cov haujlwm yuav tau ua ntawv.

UNDER OATH, I STATE THAT because of poverty, I am unable to pay

any filing and service fees, including the

electronic filing fee, or

, in

this action, proceeding, or appeal, or to give security for those fees, and request waiver of those fees. I am attaching

a copy of my pleading in this matter.

TSA TES, KUV TEEV LUS HAIS TIAS vim txoj kev txom nyem, kuv them tsis taus nqi ntawv thiab nqi tes, nrog rau

tus nqi them ua ntawv hauv tshuab hluav taws xob, lossis ntawm rooj plaub no, cov txheej txheem no, lossis kev

tawm tsam no, lossis muaj khoom txhiv cov nqi no, thiab thov kom muab cov nqi no tshem. Kuv npaj tau ib daim

ntawv thov rau cov teeb meem nov.

Complete Section 1 if you receive aid from any of the programs listed.

If you do not receive aid, complete Section 2 only.

Khij Kom Tag Rho Theem 1 yog hais tias koj tau txais kev pab los ntawm cov kev pab nram qab no.

Yog hais tias tsis tau txais kev pab, khij theem 2 kom meej xwb

Section 1 Theem 1.

I currently receive

Kuv tseem tau txais

Supplemental security income.

Nyiaj Laus/SSI.

Relief funded under §59.53(21), Wis. Stats.

Nyiaj pab cawm hauv tsab cai §59.53(21), Wis. Stats.

Medical assistance

Ntawv kho mob.

Food stamps/FoodShare.

Nyiaj Muas Noj

Relief funded under public assistance.

Nyiaj pab cawm ntawm tsoom fwv

Benefits for veterans under §45.40 (1m) or 38 USC 501-562.

Kev pab vim yog qub tub nrog hauv tsab cai §45.40 (1m) or 38 USC 501-562.

Legal representation from a civil legal services program or a volunteer attorney program based on indigency.

Kws lij choj pab dawb lossis cov kwv lij choj hauv koom haum pab neeg txom nyem.

Name of program:

Npem Ntawm Faim Kev Pab:

CV-410A, 02/16 Petition for Waiver of Fees and Costs - Affidavit of Indigency (Hmong 06/16)

§§757.675(3), 757.69(2m) and 814.29, Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.

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Form Cv-410a - Petition For Waiver Of Fees And Costs - Affidavit Of Indigency

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