REQUEST FOR RELIEF FROM COURT COSTS; DECLARATION; ORDER IN THE DISTRICT COURT OF THE FIFTH CIRCUIT STATE OF HAWAI`I Plaintiff Form 5DC13 Reserved for Court Use Civil No. Defendant Filing Party/Attorney Name, Attorney Number, Firm Name (if applicable), Address, Telephone and Fax Number or Email G Check if you are an attorney representing the filing party pro bono REQUEST FOR RELIEF FROM COURT FILING FEES Pursuant to Hawai`i Revised Statutes §607-3, the filing party in this case asks the court to waive the prepayment of court filing fees as set forth in Hawai`i Revised Statutes §607-4(b) because he or she is unable to pay such costs and provide for his or her necessities in life. Please answer the following questions: 1. Are you currently employed? Yes G No G a. If the answer is Yes, State the amount of your monthly salary/wages: $ _______________________________________________________________ Name and address of your employer: _________________________________________________________________________ _________________________________________________________________________________________________________ b. If the answer is No, State the date you were last employed:________________________________________________________________________ Name and address of your former employer: ___________________________________________________________________ _________________________________________________________________________________________________________ 2. Do you rent G or own G your home? State the amount of your monthly rent/mortgage payment: $_______________________________________________________ If you rent, do you receive any rent assistance? (Section 8) Yes G No G 3. Do you own any real estate other than your home? Yes G No G If the answer is Yes, state the total value: $ _______________________________________________________________________ 4. Do you have any money in any bank account? (Include any funds in prison accounts.) Yes G No G If the answer is Yes, state the total amount: $______________________________________________________________________ (continued on page 2) SEE PAGE 2 5D-P-179 (Rev. 08/03/2011) CommonLook® 508 Certified Reprographics (09/11) 5D Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Form 5DC13 REQUEST FOR RELIEF FROM COURT FILING FEES (continued) 5. Do you own any motor vehicles? Yes G No G 6. Do you receive any of the following (check all that apply)?: G Social Security payments (e.g. SSI or SSDI) or Retirement? G Supplemental Nutrition Assistance Program (SNAP) G Temporary Aid to Needy Families (TANF) [formerly AFDC] G Food Stamps (GA) 7. List any persons who depend upon you for financial support. State your relationship to those persons and state how much you contribute to their support. 8. Do you have any other sources of income not listed above? Yes G No G If the answer is Yes, describe what other income you receive. DECLARATION I DECLARE UNDER PENALTY OF PERJURY THAT WHAT I HAVE STATED IS TRUE AND CORRECT. Signature of Filing Party/Attorney: Date: (Reserved For Court Use) Print/Type Name: ORDER Having reviewed the request for relief from costs the court : G This request is GRANTED court filing fees are waived. G The request is DENIED. Date: Judge In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require an accommodation for a disability when working with a court program, service, or activity, please contact the District Court Administration Office at PHONE NO. (808) 482-2347, FAX(808) 482-2509, or TTY (808) 482-2533 at least ten (10) working days before your proceeding, hearing, or appointment date. 5D-P-179 (Rev. 08/03/2011) CommonLook® 508 Certified Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Form 5DC13