SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION In re estate of _____________________________ minor/ward/deceased _______ _______ _______ _______ _______ ADM INT/IDD SEB GDN TRP _______ _______ _______ _______ _______ APPLICATION TO PROCEED WITHOUT PREPAYMENT OF COSTS, FEES, OR SECURITY (in Forma Pauperis)* I, _____________________________________ am the (check one) Petitioner Guardian Heir Trustee Other: _____________________________ I need an interpreter for this case. I speak the following language: ____________________ I respectfully ask permission to proceed in this case without pre-paying costs or fees and without giving security for them because I am not able to do so without substantial hardship to myself or to my family. In support of this request, I state the following: Check and answer only those that apply in the section below. Personal Representative Conservator Legatee *This motion is filed with the Probate Division if the waiver is being requested to file a Notice of Appeal or to obtain a transcript for purposes of filing an appeal. For all other purposes, it is filed at the office of Judge-In-Chambers, 4th Floor, 500 Indiana Avenue, N.W., Washington, D.C. 20001. __________________ March 2014 ­ 819.10.v2 American LegalNet, Inc. www.FormsWorkFlow.com INCOME 1. I receive the following public benefits, and the law presumes that I am eligible to proceed without prepayment of costs, fees, or security (See D.C. Code, §15-712): Temporary Assistance for Needy Families (TANF) General Assistance for Children (GAC) Program on Work, Employment and Responsibility (POWER) Supplemental Security Income (SSI) 2. Even though I do not receive the above public benefits, I receive the following similar benefits and therefore request that my application be approved: Interim Disability Assistance (IDA) because my SSI application has not been approved/certified Medicaid DC Healthcare Alliance or the following similar health benefits (describe) _________________________________________ If you checked any of the boxes above, do not answer any more questions. Skip to the section called "Declaration." If you did not check any of the boxes above, you must answer the rest of the questions on this form. If additional information is required, you will be notified. 3. My total income over the past 12 months from all sources (including, but not limited to, my job, other wages or business income, rental income, pensions, annuities or life insurance payments, worker's compensation, unemployment compensation or insurance, annual interest or dividends, gifts, alimony or spousal support, inheritance or trust income) was $______________. 4. I am presently unemployed. The last date I worked was _______________, ________. (Month, Year) DEPENDENTS 5. How many people live in your household and depend on you for support: ________. Of these people, how many are minor children or elderly? _________. American LegalNet, Inc. www.FormsWorkFlow.com ASSETS 6. I state the following about my property: I have $__________ in cash, including money in savings or checking accounts. I own the vehicles, personal home, other real estate, stock, bonds, or other valuable property, besides household furnishings and clothing, listed below: List the Property EXPENSES 7. This is my best estimate of the monthly expenses for myself and the people in my household who depend on me for support: Housing (rent, mortgage, taxes, & insurance): Public Transportation and Gasoline: Automobile Loan, Insurance, Maintenance: Health (medical, dental, vision, prescriptions, insurance): Food and other Household Necessities: Utilities (gas, electricity, water, phone, internet) Clothing: Child Support: Childcare (including diapers, daycare): Other (explain in detail): Total Estimated Monthly Expenses: OTHER SPECIAL CIRCUMSTANCES 8. (Optional) Explain any other special circumstances that you want to have considered in support of your request, including any large monthly expenses, debts, wage or bank account garnishments, and/or judgments. $________ $________ $________ $________ $________ $________ $________ $________ $________ $________ $__________ American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION REQUIRED: I solemnly swear or affirm under criminal penalties for the making of a false statement, which includes 180 days in jail or a $1,000 fine or both, that I have read this Application and that the factual statements made in it are true to the best of my personal knowledge, information and belief. _______________________________________ Signature of filer _______________________________________ Typed name of filer _______________________________________ Address (actual address/not Post Office Box) _______________________________________ _______________________________________ _______________________________________ Telephone number _______________________________________ Email address ______________________________________ Unified Bar number (if filer is an attorney) NOTICE I understand that the Court cannot waive publication costs or bond premiums and that I am responsible for paying any such costs. If this application is granted and I later receive any assets, the Court can require me to repay all costs that were waived. If my financial situation improves, I must inform the Court immediately and begin paying costs. ___________________________________________ Signature American LegalNet, Inc. www.FormsWorkFlow.com POINTS AND AUTHORITIES IN SUPPORT OF APPLICATION TO PROCEED WITHOUT PREPAYMENT OF COSTS, FEES, OR SECURITY 1 2 3 4 5 6 7 D.C. Code § 15-712. D.C. Code § 22-2405. Civil Rule 54-II. Adkins v. E.I. Du Pont de Nemours & Co., Inc., 335 U.S. 331 (1948). Harris v. Harris, 137 U.S. App. D.C. 318, 322, 424 F.2d 806 (1970), cert. Denied, 400 U.S. 826 (1970) ("in forma pauperis relief not limited to those who are public charges or absolutely destitute"). Green v. Green, 562 A.2d 1214 (D.C. 1989) (statute "effectuates the fundamental principle that every litigant should be provided equal access to the courts without regard to financial ability"). Herbin v. Hoeffel, 727 A.2d 883, 887 (D.C. 1999) (court officers serve process in in forma pauperis status and mandating granting of petition where litigant's income "only slightly above the welfare standard"). 1 1 When you come to court, you may be asked questions about this Application. If your responses are not truthful, you could face additional criminal penalties. American LegalNet