STATE OF MAINE SUPERIOR COURT DISTRICT COURT Location Docket No. , ss Docket No. Plaintiff APPLICATION OF PLAINTIFF DEFENDANT TO PROCEED WITHOUT PAYMENT OF FEES M.R.Civ.P. 91 v. Defendant I am without funds to pay the filing fee, service costs, mediation fee, jury fee appeal fee based on the information in my attached affidavit. I am bringing this action in good faith. I agree to pay any fees or costs that may be waived if at any time during this action I am able to do so or if I receive a monetary settlement or am deemed to be the prevailing party and receive costs. I request that service costs be paid without first attempting service by mail because: Date: (Signature of party) Address: Telephone: ORDER 1. The court has reviewed the proposed pleadings. It appears that the applicant is proceeding in good faith and is without sufficient funds to pay certain fees or costs. It is ORDERED that: the filing fee is waived. the applicant's obligation to pay any part of the mediation fee is waived. The mediation fee shall be fully paid by the opposing party unless the opposing party also obtains a waiver from the court. If the opposing party does not pay the mediation fee or obtain a waiver within 14 days from the date of this Order, mediation may be scheduled at the request of the applicant and a decision on the opposing party's obligation to pay the mediation fee shall be made by further order of the court. the service costs shall be paid as an expense of administration. The applicant is to attempt service by mail with acknowledgement. If such service is unsuccessful, service by deputy or by registered mail may be authorized on motion of the applicant, accompanied by an affidavit describing the attempted service by mail with acknowledgement, and after such hearing as may be necessary. Service by publication will not be approved except on specific motion. the jury fee is waived. Other 2. The court finds the applicant has the ability to pay all or part of the fees. It is ORDERED that the applicant pay $ toward the Filing Fee, Mediation Fee, Service costs, and/or Jury fee, as follows: $ each (week)(month) beginning . 3. The decision on whether to waive or require reimbursement of the Filing Fee, Mediation Fee, Service costs, and/or Jury fee is reserved and shall be made by further order of the court. 4. The application is DENIED. If the application seeks a waiver by Plaintiff of the filing fee and Plaintiff fails to pay the filing fee within 7 days of this Order, the action shall be dismissed without prejudice. 5. If the moving party obtains a monetary settlement or is deemed to be the prevailing party fees or costs waived pursuant to this Order may be taxed as costs against the opposing party in favor of the State. This order is incorporated into the docket by reference at the specific direction of the court. Date: CV-067, Rev. 08/06 Judge / Justice / Magistrate American LegalNet, Inc. www.FormsWorkflow.com