Page 1 of 3 JDF 2 11 R10 /1 4 REQUEST TO REDUCE PAYMENT FOR ODR SERVICES AND SUPPORTING FINANCIAL AFFIDAVIT Supreme Cour t Court of Appeals Denver Juvenile Court Denver P robate C ourt County Court District Court County, Colorado Court Address: Plaintiff/Petitioner: v. Defendant/Respondent: Attorney or Party Without Attorney: (Name & Address) Phone Number: Atty. Reg. #: COURT USE ONL Y Case Number: Courtroom: REQUEST TO REDUCE PAYMENT FOR ODR SERVICES AND SUPPORTING FINANCIAL AFFIDAVIT I, respectfully request to reduce my payment for Office of Dispute Resolution Services and as grounds state that I am without funds , have no adequate funds available, and have a meritorious claim. Name of Applicant Last Name First Name MI Street Address (Include Apt. # if applicable) City State Zip Code Own Rent H ome Phone #: Social Security # Driver's Lic. # & State Date of Birth Most Recent Employer: Work Address: Work Phone #: ( ) Dates Employed: Hours/Week: Pay Rate: $ Weekly Bi - weekly Monthly Annual O ther: Name of O ther Responsible Party ( Spouse, Partner, Parent, Other Persons in Household ) Last Name First Name MI Street Address ( Include Apt. # if applicable) City State Zip Code Own Rent Home Phone #: Social Security # Driver's Lic. # & State Date of Birth Most Recent Employer: Work Address: Work Phone #: ( ) Dates Employed: Hours/Week: Pay Rate: $ Weekly Bi - weekly Monthly Annual Other: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 JDF 2 11 R10 /1 4 REQUEST TO REDUCE PAYMENT FOR ODR SERVICES AND SUPPORTING FINANCIAL AFFIDAVIT IF ADDITIONAL SPACE IS NEEDED TO PROVIDE COMPLETE INFORMATION, ATTACH A SEPARATE PAGE. Gross Monthly Income ( See Information on page 3) Monthly Expenses (See Information on Page 3) Self (wages, salary, commission) $ Rent or Mortgage $ Spouse/ Partner/ Other Household Members $ Groceries $ Parents (if same household) $ Utilities $ Unemployment Benefits $ Clothing $ Social Security/Retirement Funds $ Maintenance/Alimony $ Maintenance/Alimony $ Child Support $ Other Income (identify) $ Medical/Dental $ Other Income (identify) $ Other Expenses (identify) $ Other Income (identify) $ Other Expenses (identify) $ Total Income $ Total Expenses $ Cash on Hand ( Cash you are carrying or which is stored at home, etc.) $ Credit Cards : (Show type and balance owed) Type: Balance $ Type: Balance $ Type: Balance $ Checking Account Balance $ Name/Address of Bank : Savings Account Balance $ Name/Address of Bank: Stocks, Bonds, or other Investments Held Balance $ Type of Investmen t Name/Location of Company/Corporation Type of Investmen t Name/Location of Company/Corporation Vehicles Owned ( Autos, boats, recreational vehicles, etc .) - Estimate Value $ Year Model License Plate Year Model License Plate House(s) or other Property Estimate Value $ Amount owed, Year Purchased I swear under penalty of perjury that all information provided is true and complete. In addition, if requested I will provide three (3) months of bank statements and pay stubs or other comparable proof of income status . I authorize the Court or ODR to make any necessary contacts to verify the information that I provide . Marital Status: Single Married Partner in a Civil Union Divorced /Civil Union Dissolved Separated Widowed Number in Household: (including yourself) Identify Members: Name Age Relationship Name Age Relationship American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 JDF 2 11 R10 /1 4 REQUEST TO REDUCE PAYMENT FOR ODR SERVICES AND SUPPORTING FINANCIAL AFFIDAVIT Signature: Date: General Information It is important that you accurately complete all sections of this form as appropriate based on your personal circumstances. If a section does not apply, please write N/A. A. Gross Monthly Income . I ncludes i n come from all members of the household who contribute monetarily to the common support of the household. Income categories to include: Wages, including tips, salaries, commissions, payments received as an independent contractor for labor or services, bonuses, dividends, severance pay, pensions, retirement benefits, royalties, interest/investment earnings, trust income, annuities, capital gains, unemployment benefits, Social Security Disability (SSD), Social Security Supplemental Income (SSI), ts, and alimony. Note: Income from roommates should not be considered if such income is not commingled in accounts . Income categories do not include: disability, child support payments , or other public assistance programs. B. Liquid Assets . In clude s cash on hand or in accounts , stocks bonds, certificates of deposit, equity, and personal property or investments which could readily be converted into cash without C. Expenses . Non essential items such as cable television, club memberships, entertainment, dining out, alcohol, cigarettes, etc., shall not be included. Allowable expense categories are listed on J DF 205. American LegalNet, Inc. www.FormsWorkFlow.com