SOUTHERN JUDICIAL CIRCUIT ALTERNATIVE DISPUTE RESOLUTION PROGRAM STYLE: COUNTY: SELECTED/ASSIGNED NEUTRAL: THE UNDERSIGNED, BEING FIRST DULY SWORN ON OATH, DEPOSES AND SAYS: I am financially unable to obtain the service of a Neutral to hear my Alternative Dispute Resolution Session without causing substantial hardship to myself or to my family; the following information is true and is given and intended to be relied upon by the Administrator of the Southern Judicial Circuit ADR Program in determining my eligibility for the assistance of a Neutral to be furnished at the expense of the Southern Judicial Circuit ADR Program. I. GENERAL INFORMATION (1) Name: (2) Address: (3) Social Security No.: (5) Number of Dependent Children: II. INCOME AND ASSETS (1) Weekly income (Take-Home) (2) Employer or other source of income (including government agency) (3) If unemployed, name of last employer, and date of termination (4) Monthly or weekly income of spouse or dependents (5) Employer or other source of spouse's income (including government agency) (6) Home or other real estate: Value (7) Automobiles (8) Other assets or property (9) Money: (a) Checking Accounts (c) Savings Accounts III. EXPENSES AND DEBTS (1) Rent or Mortgage (4) Transportation (6) Medical and Dental (2) Food (5) Installment Payments (7) Insurance, i.e., (Auto, Home) (3) Utilities (b) At Home (d) Safe Deposit Box Equity (6) (4) Birth Date: Divorced Separated Married Single CIVIL ACTION NO: (8) Child Care, i.e., Day Care for Working Mothers (9) Child Support (10) Alimony American LegalNet, Inc. www.FormsWorkflow.com NAME OF CREDITOR - AMOUNT OWED NAME OF CREDITOR - AMOUNT OWED I declare under penalty of perjury that the foregoing is true and correct; I am aware that perjury is a felony punishable by a fine of not more than $1,000.00 or imprisonment for not less than one year, nor more than 10 years. READ, DATED AND SIGNED, this day of , 20 . Alternative Dispute Resolution Participant Sworn to and subscribed before me, this day of , 20 . Notary Public The above and foregoing application read and considered, the above named Alternative Dispute Resolution Participant IS/IS NOT indigent within the guidelines set by the Superior Court Judges of the Southern Judicial Circuit, and the Alternative Dispute Resolution Program WILL/WILL NOT pay the fees for the Neutral. This day of , 20 . Tim C. Hendrick, Administrator Alternative Dispute Resolution Program Southern Judicial Circuit County: File Name: File No.: Neutral: Return completed Neutral Fee Waiver Application to the Moultrie Office Attn: Tim C. Hendrick, Administrator Post Office Box 2227 - Moultrie, Georgia 31776-2227 Phone: (229) 890-5624 Fax: (229) 616-7447 American LegalNet, Inc. www.FormsWorkflow.com