__________________________________________ Full Name of Party Filing This Document __________________________________________ Mailing Address (Street or Post Office Box) __________________________________________ City, State and Zip Code __________________________________________ Telephone Number IN THE DISTRICT COURT OF THE ___________________ JUDICIAL DISTRICT OF THE STATE OF IDAHO, IN AND FOR THE COUNTY OF _____________________ _____________________________________, Plaintiff, Case No.: ___________________ MOTION AND AFFIDAVIT FOR FEE WAIVER vs. _____________________________________, Defendant STATE OF IDAHO County of _ ) ) ss. ) [ ] Plaintiff [ ] Defendant asks to start or defend this case without paying fees, Idaho Code Section 31-3220, and swears under oath: 1. This is an action for (type of case) . 2. I am unable to pay the court costs. I verify that the statements made in this Affidavit are true and correct. I understand that a false statement in this Affidavit is perjury and I could be sent to prison for one to 14 years. The waiver of payment does not prevent the court from later ordering me to pay costs and fees. MOTION AND AFFIDAVIT FOR FEE WAIVER PAGE 1 CAO 1-10A 2/25/2005 American LegalNet, Inc. www.USCourtForms.com Do not leave any items blank. If any item does not apply, write “N/A”. Attach additional pages if more space is needed for any response. IDENTIFICATION AND RESIDENCE: Name: Other name(s) I have used: Address: Phone: How long at that address? Date and place of birth: Education completed (years): __________ FAMILY: Marital Status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed [ ] Separated The following minor children live with me: Name Age Relationship Child Support Received ($/month) EMPLOYMENT: Occupation: ______________________ Employed by: _______________________________ Position: Salary: $ Monthly gross income $____________________. or $ per hour If your current position is temporary what are the start and end dates? _______________________________________________ Phone number to use to verify: . If you have held this job less than . one year, previous employer: Phone number to use to verify: . Spouse’s Occupation: ______________________. Employed by: ________________________ MOTION AND AFFIDAVIT FOR FEE WAIVER PAGE 2 CAO 1-10A 2/25/2005 American LegalNet, Inc. www.USCourtForms.com Position: Salary: $ Monthly gross income $____________________. or $ per hour If your spouse’s current position is temporary what are the start and end dates? ______________________________________ I receive assistance or support from the following sources and in the following monthly amounts: Spouse: $ Welfare: $ Food Stamps: $ Social Security: $ Unemployment Compensation: $ Former Spouse: $__________ Other (identify) Relatives: $ Retirement: $ $ If unemployed, how long since your last regular employment? List all places where you have applied for work in the last six months: Company Are you willing to work now? Last Applied Reason for Rejection What work can you do? What is the minimum wage for which you are willing to work? $_ _________ List all employers you worked for during the last three years. Company Date Terminated Ending Salary Reason for Termination Are you capable of working now? [ ] Yes [ ] No If no, why not? If a health problem keeps you from working, provide the name of your treating doctor: . Is your health problem permanent? [ ] Yes MOTION AND AFFIDAVIT FOR FEE WAIVER [ ] No PAGE 3 CAO 1-10A 2/25/2005 American LegalNet, Inc. www.USCourtForms.com When will you be released to work? ASSETS: List all real property (land and buildings) owned or being purchased by you. Legal Address City State Description Value Your Equity List all other property owned by you and state its value. Description (provide description for each item) Value Cash Notes and Receivables Vehicles: Bank/Credit Union/Savings/Checking Accounts Stocks/Bonds/Investments/Certificates of Deposit Trust Funds Retirement Accounts/IRAs/401(k)s Cash Value Insurance Motorcycles/Boats/RVs/Snowmobiles: Furniture/Appliances Jewelry/Antiques/Collectibles TVs/Stereos/Computers/Electronics Tools/Equipment Sporting Goods/Guns Horses/Livestock/Tack Other (describe) MOTION AND AFFIDAVIT FOR FEE WAIVER PAGE 4 CAO 1-10A 2/25/2005 American LegalNet, Inc. www.USCourtForms.com EXPENSES: List all of your monthly expenses. Expense Average Monthly Payment Rent/House Payment Vehicle Payment(s) Credit Cards (list last 4 digits of each account number) ____________________________________________________________________________ Loans: (name of lender and reason for loan) (Loans) Electricity/Natural Gas Water/Sewer/Trash Phone Cellular Phone Cable/Satellite TV/Internet Groceries Dining Out Clothing Auto Fuel/Transportation Auto Maintenance Cosmetics/Haircuts/Salons Entertainment/Books/Magazines Home Insurance Auto Insurance Life Insurance MOTION AND AFFIDAVIT FOR FEE WAIVER PAGE 5 CAO 1-10A 2/25/2005 American LegalNet, Inc. www.USCourtForms.com Average Monthly Payment Expense (continued) Medical Insurance Medical Expense Child Care Other MISCELLANEOUS: How much can you borrow? $ When did you file your last income tax return? From whom? _____ Amount of refund: $ PERSONAL REFERENCES: (These persons must be able to verify information provided.) Name Address Phone Years Known ___________________________________ Signature ___________________________________ Typed/Printed Name SUBSCRIBED AND SWORN TO before me this ______ day of __________________, 20____. ___________________________________ Notary Public for Idaho Residing at My Commission expires MOTION AND AFFIDAVIT FOR FEE WAIVER PAGE 6 CAO 1-10A 2/25/2005 American LegalNet, Inc. www.USCourtForms.com