REQUEST/ORDER WAIVER OF FEES - RESPONDENT PC-184A REV. 10/07 DO NOT RECORD: STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] DISTRICT NO. TO: COURT OF PROBATE, DISTRICT OF RESPONDENT IN PROCEEDINGS FOR The undersigned represents that the respondent in the above matter has a GROSS MONTHLY household income from employment of: $ leaving the NET MONTHLY INCOME shown below after deductions for: Federal withholding $ FICA and Medicare $ State withholding $ Union dues Wage executions Other $ $ $ (Please attach a copy of paycheck stub(s) for each employed household member, and explain "Other" deductions on reverse side.) $ NET MONTHLY INCOME FROM EMPLOYMENT: The undersigned further represents that the respondent has other household income (broken down monthly) as follows: Welfare $ Pension $ Social Security $ Alimony $ Unemployment Compensation $ Other income (Please explain on reverse side.) $ $ TOTAL MONTHLY INCOME FROM ALL SOURCES: The undersigned further represents that the total value of the respondent's household assets (bank accounts, etc.) is: $ The petitioner further represents that the basic expenses of the respondent's household (broken down monthly) are: Rent or mortgage $ Medical and Dental $ Utilities $ Clothing $ Food $ Other (Please explain on $ reverse side.) Total Monthly Expenses $ The undersigned further represents that the number of household members (including the respondent) supported by the respondent is: WHEREFORE, THE UNDERSIGNED REQUESTS that the Court grant a waiver of payment of Court-appointed counsel fees related to the aforementioned proceeding before this Court due to his or her inability to pay for such fees. The undersigned, if not the respondent, is familiar with the respondent's assets, income, and expenses by reason of: The representations contained herein are made under the penalties of false statement. ........................................................................................................ Type Name: Date: DISTRICT NO. COURT OF PROBATE, DISTRICT OF PRESIDING JUDGE: Hon. The foregoing request having been presented to this Court, the COURT FINDS that the above-named respondent to a waiver of fees as indicated above. is is not entitled WHEREFORE it is ORDERED and DECREED that a waiver of payment of any Court-appointed counsel fees as indicated above is granted is denied. Dated at: ,Connecticut, on [Month, Day, Year] ................................................................. Judge REQUEST/ORDER WAIVER OF FEES - RESPONDENT PC-184A American LegalNet, Inc. www.FormsWorkflow.com