Page 1 of 3 JDF 205 R10/15 MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FIN ANCIAL AFFIDAV IT Supreme Court Court of Appeals Denver Juvenile Court Denver Probate Court 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: MOTION TO : FILE WITHOUT PAYMENT OF FILING FEE WAIVE OTHER COSTS OWED TO THE STATE AND SUPPORTING FINANCIAL AFFIDAVIT I, respectfully move the Court for an order to waive the following filing fee(s): complaint petition ans wer response motion to modify other: and as grounds state that I am without funds, have no adequate funds available, and have a meritorious claim. All items must be fully completed. Print or type neatly. If an item does not apply, Name of Applicant 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 Rat e: $ 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 Ot her: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 JDF 205 R10/15 MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FIN ANCIAL AFFIDAV IT IF ADDITIONAL SPACE IS NEEDED TO PROVIDE COMPLETE INFORMATION, ATTACH A SEPARATE PAGE. Gross Monthly Income (See Information on page 3) Monthly Exp enses (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 Fund s $ Maintenance/Alimony and/or Child Support $ Maintenance/Alimony $ 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 $ Checking Account Balance $ Name/Address of Bank : Saving s Account Balance $ Name/Address of Bank: Stocks, Bonds, or other Investments Held Balance $ 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 o wed $ Year Purchased I swear under penalty of perjury that all information provided is true and complete. In addition, if requested I will pr ovide three (3) months of bank statements and pay stubs or other comparable proof of income status. I authorize the Court to make any necessary contacts to verify the information. Signature: Date: 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 205 R10/15 MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FIN ANCIAL AFFIDAV IT MOTION TO FILE WITHOUT PAYMENT SUPPORTING FINANCIAL AFFIDAVIT, AND SUPPORTING DOCUMENTATION REQUESTED 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. Includes i ncome from all members of the household who contribute monetarily to the common support of the household. Income ca tegories 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), Note: Income from roommates should not be considered if such income is not commi ngled in accounts . Income categories do not include: TANF payments, food stamps, subsidized housing assistance, vete 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 re adily be converted into cash without Expenses . Non essential items such as cable television, club memberships, entertainment, dining out, alcohol, cigarettes, etc., shall not be includ ed. Allowable expense categories are listed on J DF 205. If you are applying to have your filing fee waived you may be asked to supply: Copies of the previous three months bank statements, including checking and savings. DO NOT provide originals. Co pies of the previous three months pay stubs and/or proof of income must be included. DO NOT provide originals. American LegalNet, Inc. www.FormsWorkFlow.com