Name: Address: Telephone No: [ ]Plaintiff, Pro Se [ ]Petitioner, Pro Se [ ]Defendant, Pro Se [ ]Respondent, Pro Se IN THE FAMILY COURT OF THE SECOND CIRCUIT STATE OF HAWAI222I ) FC- No. ) Plaintiff/Petitioner, ) EX PARTE MOTION AND AFFIDAVIT ) TO WAIVE FILING FEES UNDER vs. ) HAWAI222I REVISED STATUTES ) SECTION 607-5(b); ) ORDER [ ] GRANTING [ ] DENYING ) EX PARTE MOTION Defendant/Respondent. ) ) EX PARTE MOTION AND AFFIDAVIT TO WAIVE FILING FEES UNDER HAWAI222I REVISED STATUTES SECTION 607-5(b) Plaintiff in the above-entitled action submits his/her motion to waive the filing fees, required by HRS Section 607-5(b) and, being first duly sworn on oath, deposes and says that: 1. Because of my poverty, I am unable to pay the filing fees and I believe I am entitled to relief. 2. My gross monthly income from all sources is $. I receive money from: (check all that apply) a. [ ] job: $ b. [ ] welfare: $ c. [ ] food stamps: $ d. [ ] unemployment benefits: $ e. [ ] social security: $ f. [ ] child support: $ g. [ ] part-time or side jobs: $ h. [ ] other: $ In accordance with the Ameri cans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for a disab ility, please contact the ADA Coordinator at the Family Court Administration Office at PHONE NO. 244-2700, FAX 244-2704 or email adarequest@courts.hawaii.gov at least ten (10) working days prior to your hearing or appointment date. For all Civil related matters, please call 244-2706 or visit the Service Center at 2145 Main Street, Room 141, Wailuku, HI. Ex Parte Motion and Affidavit to Waive Filing Fees Under Hawai222i Revised Statues 2F - P - 331 (Rev. 10/19/18) American LegalNet, Inc. www.FormsWorkFlow.com 3. I help to support (fill in #) dependents in my household, not including myself. 4. Within the past twelve months, I received money from the following sources: (check all that apply) a. [ ] business, profession or form of self-employment $ b. [ ] rent payments, interest or dividends $ c. [ ] pensions, investments, annuities, or life insurance payments. $ d. [ ] gifts or inheritances $ e. [ ] disability payments, lawsuit damages, etc. $ f. [ ] other: $ 5. My total assets (including but not limited to cash, bank accounts, real estate, stocks, bonds, cars, etc.) are $ . 6. I own the following: (check all that apply) a. [ ] house, townhouse, condo, other real property worth $ b. [ ] pager, cellular phone, computer worth $ c. [ ] jewelry worth $ d. [ ] firearms, collectibles, sports equipment, etc. worth $ e. [ ] car, van, truck, motorcycle, boat, etc. worth $ 7. I have a total amount of debts $ , owed on the following: a. mortgage $ b. credit cards $ c. loans $ d. other: $ I swear under penalty of perjury that the foregoing is true and correct. FURTHER AFFIANT SAYETH NAUGHT. [ ]Plaintiff [ ]Petitioner [ ]Defendant [ ]Respondent [ ] MOTION DENIED [ ] WAIVER OF FILING FEES APPROVED AND SO ORDERED SUBJECT TO REIMBURSEMENT UPON ORDER OF THE COURT Judge of the Above-Entitled Court DATED: Wailuku, Hawai222i: 2F - P - 331 (Rev. 10/19/18) American LegalNet, Inc. www.FormsWorkFlow.com