STATE OF INDIANA COUNTY OF (Select One) ) IN THE (Select One) ) SS: ) CASE NO. SUPERIOR/CIRCUIT COURT Petitioner, VERIFIED MOTION FOR FEE WAIVER V. Respondent. The Petitioner now states: 1. I wish to file this action and I believe that I have a case with merit. 2. I cannot pay any of the filing fees or other costs of this action because I do not have sufficient income or resources. 3. I live with ___________________________________________________________________. 4. 5. 6. Our family’s income is ____________ per month. (Total from below) (Income received each month, before taxes) Wages (_______ per hour x _____ hours per month) Unemployment Compensation AFDC / TANF Benefits SSI / SSD Benefits Child Support Other + Total = We have ____________ in the bank. Our expenses total ____________ per month: (Total from below) (Expenses spent each month) Housing (Rent, Contract, or Mortgage) Utilities (Gas, Electric, Water, Phone, etc.) Food Child Care Medical Bills Transportation Insurance (car, medical and/or property) Child Support Other (please describe) + _______________________________ Total = ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ I request that this Court waive all costs of this action and allow me to proceed without the payment of any filing fees or other costs. I affirm under the penalties of perjury that the foregoing representations are true. _____________________________ Signature Form #PS-33373-1 Approved by State Court Administration 02/10 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF INDIANA COUNTY OF (Select One) ) IN THE (Select One) ) SS: ) CASE NO. SUPERIOR/CIRCUIT COURT Petitioner, V. Respondent. ORDER ON FEE WAIVER The Petitioner, has filed a Verified Motion for Fee Waiver, which the Court has read and finds should be granted. IT IS THEREFORE ORDERED that Petitioner may file this case: _____ without the pre-payment of any filing fees, costs, security, bond, or other expenses; or _____ upon the pre-payment of $_____________ which is a portion of the filing fee set by statute. Such sum must be paid by the Petitioner to the Clerk within the next 20 days. The Court will determine whether any or additional costs are to be paid at a preliminary or final hearing in this case. _________________________ Date __________________________________ Judge Distribution: Form #PS-33373-1 Approved by State Court Administration 02/10 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com