IN THE SUPERIOR COURT OF_________________COUNTY STATE OF GEORGIA APPLICATION FOR EXEMPTION FROM PAYMENT OF FEES FOR SEMINAR FOR DIVORCING PARENTS ___________________________________________________________________ INSTRUCTIONS: Complete this form if you are unable to pay the $45.00 registration fee for the mandatory Seminar for Divorcing Parents. Return the completed form to the Office of the Clerk of Superior Court. The clerk or a deputy clerk will review the information provided on the form and determine if, based on the guidelines for indigency, you are qualified for exemption from paying the registration fee. The completed form must be signed in the presence of a notary public of the State of Georgia. Section 1. Applicant/Case Information (1) Civil Action Number:__________ (2) Type Action:______________________ (2) Plaintiff(s):_________________________________________________________________ (3) Defendant(s):_______________________________________________________________ (4) Name of Party Completing this Application:______________________________________ (5) Size of Party's Family:_________ (6) Party's Monthly Family Income:___________ (From All Sources) (7) Check one: (a) I own property shown on the reverse side of application:____________ (b) I do not own any property (listed on reverse side of this application).__ Section 2. Applicant Affidavit I, the party named in (4) above, am a party in the Liberty Superior Court civil action stated in (1) above. The action is domestic in nature and, as required by an order of said superior court, I am therefore required to attend "Helping Children Cope," a seminar for divorcing parents. A registration fee is charged for the seminar. I request that the fee requirement be waived because of my indigency. Under oath, I hereby certify that the size of my family unit is as stated in (5) above, that my family's income is as shown in (6), and that I do or do not own property shown on the reverse side of this form, as specified by me in (7) above. I am aware that, if I make a false statement on this form, I can be prosecuted and/or sued in accordance with applicable Georgia criminal and civil laws pertaining to false swearing and fraud. _______________________________ Notary Public Date:___________________________ My Commission Expires:___________ ____________________________________ Signature of Applicant Date:_______________________________ American LegalNet, Inc. www.FormsWorkFlow.com Section 3. Assets of Applicant Note: List all real property (land) and personal property (buildings, cars, boats, jewelry, etc.) you own. Real Property (attach additional sheet if necessary). Location Amount (8) List all land you own: (A)_______________ ________________________ (B)_______________ ________________________ (C)_______________ ________________________ (D)_______________ ________________________ Value __________ __________ __________ __________ Amount Owed Lender/To Whom Owed (9) Amount you owe for: (A)______________ ____________________________________ (B)_______________ ____________________________________ (C)_______________ ____________________________________ (D)_______________ ____________________________________ Personal Property (attach additional sheet if necessary). Value Description (10) Personal property (A)_______________ ____________________________________ owned (i.e., cars, (B)_______________ ____________________________________ boats, jewelry, (C)_______________ ____________________________________ etc.) (D)_______________ ____________________________________ Amount Owed Lender/To Whom Owed (A)_______________ ____________________________________ (B)_______________ ____________________________________ (C)_______________ ____________________________________ (D)_______________ ____________________________________ (11) Amount you owe: for any personal property listed in (10) above. American LegalNet, Inc. www.FormsWorkFlow.com