Request/Order Waiver of Fees (Petitioner) PC-184 REV. 7/19 CONNECTICUT PROBATE COURTS PC-184 RECEIVED: Instructions: 1) A petitioner in a probate matter may use this form to establish that he or she is indigent and unable to pay probate fees and expenses for which the petitioner may be responsible. The petitioner must include both the petitioner222s information and information for the petitioner222s household. A household is one or more individuals who rely on themselves or one another for support. 2)A fiduciary or attorney may file this form on behalf of a person they represent. The fiduciary or attorneyshould include only the petitioner222s household information and not the fiduciary or attorney222s information. 3)Include with this form documentation substantiating the reported assets and income. For example, paystubs from employment and evidence of public assistance. 4)There is a rebuttable presumption that the petitioner is indigent if: (a) he or she receives publicassistance OR (b) the annual income of the petitioner222s household is 125% or less of the federal poverty level after taxes, other mandatory payroll deductions and child care expenses. 5)Type or print in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Court Name District Number In the Matter of Petitioner (Name and address) Type of Matter The undersigned represents that: 1) Total number of people in the household, including the petitioner: 2 ) Net monthly household income from employment after taxes and mandatory payroll deductions : 3 ) Other monthly household income: a) Public Assistance (Specify) Public assistance includes: state-administered general assistance; temporary familyassistance; aid to the aged, blind and disabled; supplemental nutrition assistance; and supplemental security income also known as SSI. b) Social Security c) Pension d) Unemployment Compensation e) Other (Specify) Total other monthly household income (Items 3a through 3e above) Total net monthly household income (Items 2 and 3 above) American LegalNet, Inc. www.FormsWorkFlow.com Request/Order Waiver of Fees (Petitioner) PC - 184 REV. 7/19 CONNECTICUT PROBATE COURTS In the Matter of PC-184 The undersigned further represents that: 1) Estimated value of household assets: a) Real estate net value (subtract outstanding mortgages or liens) b) Motor v ehicles net value (subtract outstanding loans or liens) c) Balance of all savings accounts d) Balance of all checking accounts e) Cash f) Other (Specify) Total net value of household assets (Items 1a through 1f above) 2) Current household liabilities/debts (excluding any above mortgages/loans): a) Credit card balance b) Other (Specify) Total current household liabilities (Items 2a through 2b above) 3) Estimated reoccurring monthly household expenses : a) Rent/Mortgage p ayment b) Motor v ehicle l oan p ayments c) Other transportation costs (bus, gasoline) d ) Property t axes e ) Utilities f ) Insurance premiums (medical, auto, home, etc.) g) Medical and dental h ) Food i ) Clothing j ) Child c are k ) Other (Specify) Total reoccurring monthly household expenses (Items 3a through 3k above) The undersigned requests that the court grant a waiver of fees and expenses in the above matter for which the petitioner may be responsible because the petitioner is indigent and unable to pay the fees and expenses. The representations made in this petition are made under penalty of false statement. Signature of Petitioner or R epresentative Type or Print Name Title or Relationship (if applicable) Date American LegalNet, Inc. www.FormsWorkFlow.com Request/Order Waiver of Fees (Petitioner) PC - 184 REV. 7/19 CONNECTICUT PROBATE COURTS In the Matter of PC-184 For Court Use Only Probate Court Name District Number PRESIDING JUDGE: Hon. The foregoing request having been presented to the court, the COURT FINDS that the petitioner: is indigent and entitled to a waiver of fees and expenses as requested above. is not indigent. WHEREFORE, it is ORDERED and DECREED that the request for waiver of fees and expenses is: GRANTED. DENIED. Dated at: , Connecticut, on [Month, Day, Year] Judge American LegalNet, Inc. www.FormsWorkFlow.com