IN THE DISTRICT COURT OF APPEAL FOR THE STATE OF FLORIDA FIFTH DISTRICT Appellant(s), v. Appellee(s) Appellate Case No. 5D County Case No. / DATE: MOTION FOR WAIVER OF MEDIATION FEES Appellant(s), , through undersigned counsel, hereby move(s) for waiver of mediator's fees and, in support thereof, submits the attached affidavit, and would state that payment of such fees would create an undue financial burden for the following reasons: I hereby certify that the above information is true and correct. Appellant(s), (Name) (Address) (City/State/Zip) Attorney for Appellant(s) (Name) (Address) (City/State/Zip) NOTE: Signatures by both party and counsel are required. CERTIFICATE OF SERVICE (Counsel222s Certificate of Service that complies with Florida Rule of Appellate Procedure 9.420(d)(1) must be attached to this motion) This motion and attached affidavit should be e-filed with the Fifth District Courtof Appeal via t American LegalNet, Inc. www.FormsWorkFlow.com Rev. 02-2007 IN THE DISTRICT COURT OF APPEAL FOR THE STATE OF FLORIDA FIFTH DISTRICT Appellant(s), v. Appellee(s) Appellate Case No. 5D County Case No. / AFFIDAVIT IN SUPPORT OF MOTION FOR WAIVER OF MEDIATION FEES I, , being first duly sworn, depose and make under oath the following statement regarding my age, marital status, dependents, and financial condition. AGE: DATE OF BIRTH: DEPENDENTS: MARITAL STATUS: Married Separated Divorced Single FINANCIAL CONDITION: Affiant's Gross Income: Weekly $ Bi - Weekly $ Monthly $ Spouse's Gross Income: Weekly $ Bi - Weekly $ Monthly $ Own Home Yes No Monthly Payments $ Rent Home Yes No Monthly Rent Payment $ Value of Real Estate Owned [home, lot(s), etc.]: $ Own Automobile Yes No Monthly Payment $ Value of A utomobile $ Year/Make Value of Personal Property Owned (boats, stocks, jewelry, etc.) $ Value of Personal Debt $ By: Address: Signature of Affiant S TATE OF FLORIDA COUNTY OF SWORN TO AND SUBSCRIBED TO BEFORE ME THIS DAY OF 20 Personally known to me Produced identification: My Commission Expires: Notary Public, State of Florida American LegalNet, Inc. www.FormsWorkFlow.com