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Request For Exemption From Payment Of Fees Form. This is a Alaska form and can be use in Trial Court Statewide.
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Tags: Request For Exemption From Payment Of Fees, TF-920, Alaska Statewide, Trial Court
To Clerk: Do not issue summons until request is granted or filing fee is paid.
IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA
AT _______________________
Plaintiff,
vs.
Defendant.
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CASE NO.
REQUEST FOR EXEMPTION
FROM PAYMENT OF FEES
I,
, request exemption from payment of the fees
listed in Administrative Rule 9(f)(1) due to my financial inability to pay.
FINANCIAL STATEMENT
Phone:
Residence Address:
Mailing Address:
Present Employer:
Employer’s
Address:
Date of Birth:
(If not now employed, state last employer and date terminated)
Employer’s
Phone:
1.
INCOME INFORMATION (after taxes, but before other deductions)
a.
Income during last 12 months:
You
Your Spouse
Wages .........................................
Public Assistance ........................
Unemployment ............................
Other
(Specify)
TOTAL:
b.
Current monthly income from
all sources:
2.
FAMILY MONTHLY EXPENSES:
Food
Rent
Utilities
Car payments
Furniture & Equipment payments
Child support or alimony
Loans/Time payments
TOTAL EXPENSES:
Page 1 of 2
TF-920 (10/06)(cs)
REQUEST FOR EXEMPTION FROM PAYMENT OF FEES
Adm. R. 9(f)(1) and 10
Civil R. 90.3
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3.
FAMILY ASSETS – Present Value:
Cash on hand or
in bank
Land, buildings or
trailers
Cars
Snow machines, boats
airplanes or other
motor vehicles
(except cars)
Securities: stocks,
bonds, notes
Businesses
Other Assets:
4.
FAMILY DEBTS:
Mortgages
Loans
Charge cards
Other (bills, etc.):
TOTAL DEBT:
TOTAL ASSETS:
5.
DEPENDENTS:
Name
Age
Relationship
I swear or affirm that this financial statement is true. I understand that if I give false information
in the financial statement, I may be prosecuted for perjury.
Date
Signature of Plaintiff/Defendant
Subscribed and sworn to or affirmed before me at
on
.
(date)
(SEAL)
, Alaska
Notary Public/Judge/Court Clerk
My Commission Expires:
ORDER
It is ordered that the request for exemption from payment of fees is:
GRANTED. Plaintiff/Defendant is exempted from payment of the fees specified in
Administrative Rule 9(f)(1).
DENIED. Any fees now due in this case must be paid before any further action is taken. If
payment is not made within 30 days after notice of the order, the court may dismiss the
action. Admin.Rule 10(d).
Date
I certify that on
a copy of this order was sent to:
Judge/Magistrate
Type or Print Name
Clerk:
Page 2 of 2
TF-920 (10/06)(cs)
REQUEST FOR EXEMPTION FROM PAYMENT OF FEES
Adm. R. 9(f)(1) and 10
Civil R. 90.3
American LegalNet, Inc.
www.FormsWorkflow.com
