County Court District Court Denver Juvenile Court Denver Probate Court _________________________________________ County, Colorado Court Address: COURT USE ONLY Plaintiff/Petitioner:________________________________________ Case Number: Courtroom: v. Defendant/Respondent: __________________________________ MOTION TO: FILE WITHOUT PAYMENT OF FILING FEE APPOINT AND PAY INTERPRETER COSTS AND SUPPORTING FINANCIAL AFFIDAVIT I, _____________________________________ respectfully move the Court for an order to waive the following filing fee(s): complaint petition answer response motion to modify other: __________________ and/or to appoint and pay for an interpreter for the following language _________________________ pursuant to CJD 06-03 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, please write “N/A” Name of Applicant Other Responsible Party (Spouse, Parent, Other Persons in Household) Last Name First Name MI Street Address (Include Apt. # if applicable) State First Name MI Street Address (Include Apt. # if applicable) ____________________________________________________ ______________________ ____________ City Last Name Zip Code ____________________________________________________ ______________________ ____________ City State Zip Code Own Rent Home Phone #: _____________________ Social Security # Driver's Lic. # & State Date of Birth Own Rent Home Phone #: ____________________ Social Security # Driver's Lic. # & State Date of Birth Most Recent Employer: ______________________________ Most Recent Employer: ______________________________ Work Address: _____________________________________ Work Address: _____________________________________ Work Phone #: ( Work Phone #: ( ) _______________________________ ) _______________________________ Dates Employed: ___________________________________ Dates Employed: ___________________________________ Hours/Week: ___________ Pay Rate: $ ________________ Hours/Week: ____________ Pay Rate: $ ________________ Pay Dates: Pay Dates: Marital Status: Single Married Divorced ____ Identify Name, Age, and Relationship: Separated Gross Monthly Income (See Information on page 2) Widowed Number in Household: (including yourself) Monthly Expenses (See Information on Page 2) Self (wages, salary, commission) Spouse/Other Household Members Parents (if same household) Unemployment Benefits Social Security/Retirement Funds Maintenance/Alimony Other Income (identify) Other Income (identify) $ $ $ $ $ $ $ Rent or Mortgage Groceries Utilities Clothing Maintenance/Alimony and/or Child Support Medical/Dental Other Expenses (identify) Other Expenses (identify) $ $ $ $ $ $ $ $ $ $ Total Income Total Expenses If incarcerated, amount in Inmate Account $ ________________. (Attach copy of Inmate Trust Fund Account statement for a six-month period immediately preceding filing pursuant to §13-17.5-103, C.R.S.) Cash on Hand (Cash you are carrying or $ Credit Cards: (Show type and balance owed) which is stored at home, etc.) Name/Address of Bank Checking Account Balance $ Savings Account Balance $ Name/Address of Bank: Stocks, Bonds, or other Investments Held Balance Vehicles Owned (Autos, boats, recreational vehicles, etc.) - Estimate Value House(s) or other Property - Estimate Value $ Type of Investment, Name/Location of Company/Corporation $ Identify Year _______Model ____________License Plate__________ Identify Year _______Model ____________License Plate__________ $ Amount owed, Year Purchased IF ADDITIONAL SPACE IS NEEDED TO PROVIDE COMPLETE INFORMATION, ATTACH A SEPARATE PAGE. I swear under penalty of perjury that all information provided is true and complete. In addition, I authorize the Court to make any necessary contacts to verify the information. JDF 205 R9/08 MOTION TO: FILE WITHOUT PAYMENT OF FILING FEE/APPOINT AND PAY INTERPRETER AND SUPPORTING FINANCIAL AFFIDAVIT American LegalNet, Inc. www.FormsWorkflow.com Signature: ___________________________________ Date: ___________________ JDF 205 R9/08 MOTION TO: FILE WITHOUT PAYMENT OF FILING FEE/APPOINT AND PAY INTERPRETER AND SUPPORTING FINANCIAL AFFIDAVIT American LegalNet, Inc. www.FormsWorkflow.com MOTION TO FILE WITHOUT PAYMENT AND SUPPORTING FINANCIAL AFFIDAVIT 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 income 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), Workman’s Compensation Benefits, and alimony. Note: Income from roommates should not be considered if such income is not commingled in accounts or otherwise combined with the applicant’s income in a fashion which would allow the applicant proprietary rights to the roommate’s income. Income categories do not include: TANF payments, food stamps, subsidized housing assistance, veteran’s benefits earned from a disability, child support payments, or other public assistance programs. B. Liquid Assets. Includes 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 jeopardizing the applicant’s ability to maintain home and employment. C. Expenses. Nonessential items such as cable television, club memberships, entertainment, dining out, alcohol, cigarettes, etc., shall not be included. Allowable expense categories are listed on JDF 205. JDF 205 R9/08 MOTION TO: FILE WITHOUT PAYMENT OF FILING FEE/APPOINT AND PAY INTERPRETER AND SUPPORTING FINANCIAL AFFIDAVIT American LegalNet, Inc. www.FormsWorkflow.com