COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. The Tallapoosa Judicial Circuit : Calendar No. Juvenile Mediation Program : Plaintiff(s) Indigent Fee Waiver -against- JUDICIAL SUBPOENA : : The juvenile and the juvenile’s legal guardian requesting a fee waiver for the portion of supervision fees associated with the cost of mediation should complete this form and : return it to the mediation office. If you need assistance with this form, please call (770) 387-4807 between 8:30 a.m. and 4:30 p.m. Defendant(s) : ...................................................... Name of Party Requesting Waiver: ___________________________________ Relationship to Juvenile: ___________________________________________ THE PEOPLE OF THE STATE OF NEW YORK TO Case Name: _____________________________________________________ Case Number: _______________________ County: ____________________ GREETINGS: I, ___________________________, personally appeared before the undersigned officer WE COMMAND YOU, that all business State of Georgia, and having been each of you duly authorized to administer oaths in the and excuses being laid aside, you andsworn, stateattend before , the Honorable at the Court the following: located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed SECTION 1. or adjourned date, to testify and give evidence as a witness in this action on the part of the Affiant is a United States citizen above the age of eighteen (18) years, under no legal disability, and has personal knowledge sufficient to make this affidavit in connection with the above-styled action. this subpoena is punishable as a contempt of court and will make you liable to Your failure to comply with the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. SECTION 2. Affiant is the juvenile’s legal guardian in the above referenced case that has been referred Witness, Honorable , one of the Justices of the Court to mediation. Affiant and juvenile are unable to pay the $50.00 supervision fee. in County, day of , 20 SECTION 3. Affiant provide the following information: (Attorney must sign above and type name below) 1. Are you employed? _______ Name of Employer_________________ Attorney(s) for 2. Monthly take home pay _________ 3. Additional income: This includes child support, alimony, welfare, social security, workman’s comp, unemployment, food stamps, or disability. __________________________________________________________________ Office and P.O. Address 4. List everyone that lives in your home: Telephone No.: Name Relationship Facsimile No.: _________________________ _______________________ E-Mail Address: _________________________ _______________________ Mobile Tel. No.: _________________________ _______________________ Income _____________ _____________ _____________ American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. 5. List any extraordinary living expenses and amount (such as regularly occurring medical expenses or child care) : __________________________________________________________________ JUDICIAL SUBPOENA Plaintiff(s) -against- Juvenile provide the following information: 1. Are you employed? ______ 2. Monthly take home pay_______ : : Name of Employer____________________ : Defendant(s) : ...................................................... The undersigned Affiant and Juvenile swears the information given herein is true and correct and understands that a false answer to any item may result in prosecution for a felony and/or contempt of Court. THE PEOPLE OF THE STATE OF NEW YORK TO FURTHER SAITH THE AFFIANT NOT. The ________ day of ______________, 20_____. GREETINGS: ____________________________________ WE COMMAND YOU, that all business andAffiant’sbeing laid aside, you and each of you attend before excuses Signature , the Honorable at the Court ____________________________________ located at County of Juvenile’s Signature in the in room , on the day of , 20 , at o'clock noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Sworn to and subscribed before me This ____ day of ___________, 20_____. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Court in _________________________________ Notary Public Witness, Honorable My commission expires _____________. County, day of , one of the Justices of the , 20 The above and foregoing application read and considered, the above named Juvenile (Attorney must sign set and type name below) Mediation Participant IS / IS NOT indigent within the guidelinesaboveby the indigent defense counsel. This ________ day of ___________________________, 20_______. Attorney(s) for __________________________________ AdministratorOffice and P.O. Address Juvenile Mediation Program Tallapoosa Judicial Circuit Telephone No.: Facsimile No.: Return this form to: 7th JAD, Juvenile Mediation Program, P. O. Box 963, E-Mail Address: Cartersville, Georgia, 30120 Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com