POVERTY APPLICATION FOR REDUCTION NINTH JUDICIAL ADMINISTRATIVE DISTRICT OFFICE OF DISPUTE RESOLUTION P. O. Box 1236 501 Candler Street NE Gainesville, Georgia 30503 Telephone: 770.535.6909 Facsimile: 770.531.4072 PLEASE READ CAREFULLY AND COMPLETE EXACTLY AS DIRECTED Parties who feel they qualify for a fee reduction are responsible for contacting the 9 th JAD ODR and requesting a fee reduction application be mailed to them or, the form can be downloaded from our website at www.adr9.com. The original form must be submitted to our office. We cannot accept a faxed or emailed copy. The Fee Reduction Request Form must be received in the 9th JAD ODR ten (10) working days (Monday thru Friday, 8:30 am – 5:00 p.m.) prior to the scheduled mediation session or seminar date. Any of the following will result in automatic disqualification for a fee reduction, regardless of the person’s ability to pay: Fee reduction requests received less than ten (10) days prior to the scheduled mediation session or seminar date; incomplete case and/or personal information; Failure to disclose requested financial information; False or incomplete information; Improperly completed applications. If you have questions about this form, please call 770.535.6909 between 8:30 a.m. and 5:00 p.m. It is the responsibility of the party requesting the fee reduction to contact our office prior to your date for mediation or seminar to determine if you qualify for a fee reduction. Name of Party Requesting Reduction: _____________________Social Security Number______________ Mailing Address: _______________________________Physical Address: ___________________________________________ Telephone Numbers: Home: ______________, Work ________________, Cell, __________________ Other ___________ Case Name/Style: _________________________________________ Civil Action Filing Number: ________________________ County in which Case is Filed: _____________________________ Assigned Judge: _________________________________ IF ABOVE CASE INFORMATION SECTION IS NOT FILLED OUT COMPLETELY, YOUR REQUEST FOR A FEE REDUCTION WILL NOT BE CONSIDERED. 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, you, 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 a party in the above referenced case which has been referred to the Office of Dispute Resolution for _______MEDIATION ______SEMINAR ______BOTH. Affiant is unable to pay normal fee rates. Section 3. Affiant provides the following information: Social Security Number____________________________ Name of Employer_________________________________________ Supervisor Name and Telephone Number ______________________________________________________________________ If unemployed: How long unemployed? _________________ Most recent Employer__________________________________ Reason for Unemployment _________________________________________________________________________________ DEPENDENTS – List all children under the age of 18 living in your household: Name Relationship __________________________________ _______________________________ __________________________________ _______________________________ __________________________________ _______________________________ Age ____________ ____________ ____________ American LegalNet, Inc. www.FormsWorkFlow.com List all other persons in the household in which you are residing not listed above as dependents: Name __________________________________ __________________________________ __________________________________ __________________________________ Relationship _______________________ _______________________ _______________________ _______________________ Age ____ ____ ____ ____ Employment ________________________________ ________________________________ ________________________________ ________________________________ INCOME Wages Affiant $__________Gross per month (copy of recent paycheck stub required and to be submitted with this form) Other Household Member $__________Gross per month Employer: _________________________________________________ (copy of recent paycheck stub required and to be submitted with this form) Other Household Member $__________Gross per month Employer: ________________________________________________ (copy of recent paycheck stub required and to be submitted with this form) Other Income: $___________per month Alimony or Child Support List type(s) of support: __________________________________________________________ $__________ per month Social Security, VA, Welfare, Food Stamps, Well Care/Peach Care or other assistance program. List type(s) of assistance _________________________________________________ $__________per month Other income such as interest income, dividends, rent, royalties, or from any other sources. Source of other income __________________________________________________________ $__________per month Other assistance received and total amount such as monies from family members, churches, civic organizations or from any other persons or organizations including gifts, use of vehicle, or equipment. Name of Source and relationship, if any _____________________________________________ $__________________ TOTAL INCOME per month and $_______________ TOTAL INCOME per year ASSETS (If these assets below will increase future interest, please put them in the “Income” section above.) $__________________ Cash on hand or any money not in a bank $__________________ Money in checking, savings or any other financial accounts. List financial institution(s) and amounts _____________________________________________ $__________________ Real Estate (houses, property, buildings, etc.) List current market value. Amount owed $__________________________________________________ Name of Mortgage Holder such as bank, etc. ____________________________ Listed in whose name? ____________________________________________ $__________________ Vehicles (make, model, year) car, truck, boat, tractor, van, motorcycle, recreational vehicle (RV, all terrain vehicle (ATV) or any other vehicle. List current market value. Amount owed $__________________________________________________ Titled/Registered in whose name? ___________________________________ $__________________ Other non-necessity items such as: jewelry, IPod, MP3 Player, Bluetooth, video camera recorder, digital camera, etc. List make, and model if applicable. List current market value of all. __________________________________________ $__________________ Income Tax refund $__________________ TOTAL ASSETS _________Expected receipt date ________Date received American LegalNet, Inc. www.FormsWorkFlow.com Other non-necessity items: Fill out completely. In the last row list any other non essential items that are not already included below. ITEMS IN HOUSEHOLD HOUSEHOLD MEMBER USING DEVISE DATE OF PURCHASE OR DATE GIVEN AS GIFT MANUFACTURER MODEL (WITH NUMBER) COST IF PURCHASED; VALUE IF GIFT WEEKLY, MONTHLY OR ANNUAL BILL / SERVICE COSTS COMPUTER (S) LAPTOP(S) PRINTER (S) PDA(S) Cell/Mobile Phone(s) Blue Tooth(s) MP3(s) IPod(s) Camera(s) DIGITAL, ETC. Video Camera(s) TELEVISION(S) DVD, DVR, TEVO, WII, SURROUND SOUND, ETC. TV SERVICE SUCH AS CABLE, DIRECT TV, DISH NETWORK, ETC ALL JEWELRY OTHER ITEM(S) American LegalNet, Inc. www.FormsWorkFlow.com DEBTS $__________per month Alimony or child support paid by affiant. Paid to: Name_________________________________________________________________ Address________________________________________________________________ Telephone Number ______________________________________________________ Paid by: (direct deposit, garnishment, in person, etc.) ___________________________ $__________per month Unusually large bills or extraordinary living expenses, such as for a catastrophic or terminal illness for self or dependent. Explain.______________________________________________ _____________________________________________________________________________ $__________________ TOTAL DEBTS per month and $ __________________ TOTAL DEBTS per year Section 4. Affiant states that (Choose one of the following): _____a. she/he represents herself/himself in this action. _____b. she/he is represented by counsel and counsel has not yet been paid anything. Name of Counsel ________________ _____c. she/he is represented by counsel at no expense. Name of Counsel _______________________________________ _____d. she/he is represented by counsel that has been paid in full or partially paid. Amount Paid ____________________ Name of Counsel ________________ Section 5. SWORN STATEMENT: Upon my oath, I swear that I have no assets with which to pay the full amount for mediation and/or the seminar, and all statements given on all pages of this request for fee reduction are true and correct. I am aware that false swearing is a felony punishable by a fine of not more than $1,000.00 and/or imprisonment for not less than one year or more than five years. Affiant’s signature releases the 9th JAD ODR to contact all entities necessary to determine income, assets and validity of all information provided in this request for fee reduction. 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 ___________. (SEAL) American LegalNet, Inc. www.FormsWorkFlow.com