Page 1 of 2 Office of Dispute Resolution SEVENTH JUDICIAL ADMINISTRATIVE DISTRICT P.O. BOX 963 CARTERSVILLE, GA 30120 www.7jad.com PHONE: (770) 387-4820 TOLL FREE: (877) 655-6865 FAX: (770) 387-5479 Indigent Fee Waiver Form The party requesting a fee waiver/fee reduction for the cost of mediation should complete this form and return it along with a copy of their most recent Federal tax return to the above address. This form must be received by the ADR Office ten (10) days prior to the mediation session. Late or incomplete forms will not be accepted. The requesting party is responsible for notifying the mediator of the results prior to the mediation session. If you need assistance, please call the ADR Office. Name: (Last, First MI) Mail Address City, State and Zip Phone County Assigned Judge Civil Action # Style of Case (example: Doe vs Doe) I, ________________________________, personally appeared before the undersigned officer duly authorized to administer oaths in the State of Georgia, and having been sworn, state the following: SECTION 1 Affiant is a United States citizen above the age of eighteen (18) years, under no legal disability, and has personal knowledge sufficient to make this affidavit in connection with the above-styled action. SECTION 2 Affiant is the Plaintiff / Defendant (CIRCLE ONE) in the above referenced case which has been referred by the assigned judge to mediation. Affiant is unable to pay (select one of the following): ____All of the mediation costs of this action and is therefore requesting a fee waiver. ____Any of the mediation costs in this action and is therefore requesting a fee reduction. ____Affiant states that mediation fees can be paid so long as fees do not exceed $________. SECTION 3 Affiant provides the following information: 1. Are you working? Y/N Name of Employer: _____________________________ 2. Net Income: ______________________ (Monthly) 3. List every source and amount of additional income: This includes child support, alimony, welfare, social security, workman's comp, unemployment, food stamps, or disability. ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ __________________________________________________ 4. List everyone that lives in your home: Name _________________________ _________________________ _________________________ _________________________ _________________________ 5. Do you own your home? Y / N Relationship / Age Net Income __________________________ ________________ __________________________ ________________ __________________________ ________________ __________________________ ________________ __________________________ ________________ Value _______________ Balance American LegalNet, Inc. www.FormsWorkFlow.com 6. List Checking, Savings or Money Market Accounts Institution Type / Account No. Page 2 of 2 __________________________ __________________________ __________________________ __________________________ _______________________ _______________________ _______________________ _______________________ _________________ _________________ _________________ _________________ 7. List any other property of value (jewelry, real estate, etc.) ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ __________________________________________________ 8. Amount of monthly house payment or rent ____________________ 9. List all indebtedness Creditor ______________________ ______________________ ______________________ ______________________ Account No. Balance Monthly Payment ___________________ _____________ _______________ ___________________ _____________ _______________ ___________________ _____________ _______________ ___________________ _____________ _______________ 10. List any extraordinary living expenses and amounts (such as regularly occurring medical expenses, prescriptions, childcare, etc.) ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ __________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ SECTION 4 Affiant states that (select one of the following): ______ she/he represents herself/himself in this action. ______ she/he is represented by counsel and counsel has not yet been paid. ______ she/he is represented by counsel at no expense. SECTION 5 The undersigned Affiant swears the information given herein is true and correct and understands that a false answer to any item may result in prosecution for a felony and/or contempt of Court. FURTHER SAITH THE AFFIANT NOT. This ___________ day of ____________________, 20_______. _______________________________________ Affiant's Signature Sworn to and subscribed before me This ___________ day of ____________________, 20_______. ______________________________ Notary Public My commission expires ________________. Services are provided and admissions/referrals are made without regard to race, color, religious creed, ancestry, gender, sexual orientation, disability, age or national origin. Complaints of discrimination may be filed with the Seventh Administrative District Office. American LegalNet, Inc. www.FormsWorkFlow.com