R equest/Order Waiver of Fees (Other than Petitioner) PC-184A REV. 7/19 CONNECTICUT PROBATE COURTS Request/Order Waiver of Fees (Other than Petitioner) PC - 184A Page 1 of 3 RECEIVED: Instructions: 1) A respondent , minor child, conserved person or protected person may use this form to establish that he or she is indigent and unable to pay attorney222s fees and other fees and expenses for which the individual may be responsible. A person familiar with the income, assets and expenses may file this form on behalf of the individual. 2)A fiduciary or attorney may file this form on behalf of the person they represent. The fiduciary orattorney should include only the individual222s information and not the fiduciary or attorney222s information. 3)Include with this form documentation substantiating the reported assets and income. For example, paystubs from employment and evidence of public assistance. 4)There is a rebuttable presumption that the individual is indigent if (a) he or she receives publicassistance OR (b) the annual income of the individual is 125% or less of the federal poverty level after taxes, other mandatory payroll deductions, and child care expenses. 5)Type or print in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Court Name District Number In the Matter of Name of Respondent (if different) Name and address of person filing request Type of Matter The undersigned represents that: 1 ) Net monthly income from employment after taxes and mandatory payroll deductions : 2 ) Other monthly income: a) Public Assistance (Specify ) Public assistance includes: state - administered general assistance; temporary family assistance; aid to the aged, blind and disabled;supplemental nutrition assistance; and supplemental security income also known as SSI. b) Social Security c) Pension d) Unemployment Compensation e) Other (Specify) Total other m onthly income (Items 2 a through 2 e above) Total net monthly income (Items 1 and 2 above) American LegalNet, Inc. www.FormsWorkFlow.com Request/Order Waiver of Fees (Other than Petitioner) PC - 184A REV. 7/19 CONNECTICUT PROBATE COURTS In the Matter of Request/Order Waiver of Fees (Other than Petitioner) PC - 184A Page 2 of 3 The undersi gned further represents that: 1) Estimated value of assets: a) Real estate net value (subtract outstanding mortgages or liens) b) Motor v ehicles net value (subtract outstanding loans or liens) c) Balance of all savings accounts d) Bala nce of all checking accounts e) Cash f) Other (Specify) Total net value of assets (Items 1a through 1f above) 2) The current liabilities/debts (excluding any above mortgages/loans): a) Credit card b alance b) Other (Specify) Total current liabilities (Items 2a through 2b above) 3) The estimated reoccurring monthly expenses : a) Rent/Mortgage p ayment b) Motor Vehicle l oan p ayments c) Other t ransportation costs (bus, gasoline) d ) Property t axes e ) Utilities f ) Insurance premiums (medical, auto, home, etc.) g) Medical and dental h ) Food i) Clothing j) Child c are k) Other (Specify) Total reoccurring monthly expenses (Items 3a through 3k above) The undersigned requests that the court grant a waiver of fees and expenses in the above matter for which the respondent, minor child, conserved person or protected person may be responsible because the individual is indigent and unable to pay the fees and expenses. The representations made in this petition are made under penalty of false statement. Signature Type or Print Name Title or Relationship (if applicable) Date American LegalNet, Inc. www.FormsWorkFlow.com Request/Order Waiver of Fees (Other than Petitioner) PC - 184A REV. 7/19 CONNECTICUT PROBATE COURTS In the Matter of Request/Order Waiver of Fees (Other than Petitioner) PC - 184A Page 3 of 3 For Court Use Only Probate Court Name District Number PRESIDING JUDGE: Hon. The foregoing request having been presented to the court, the COURT FINDS that the respondent, minor child, conserved person or protected person: is indigent and entitled to a waiver of fees and expenses as requested above. is not indigent. WHEREFORE, it is ORDERED and DECREED that the request for waiver of fees and expenses is: GRANTED. DENIED. Dated at: , Connecticut, on [Month, Day, Year] Judge American LegalNet, Inc. www.FormsWorkFlow.com