Page 1 of 3REQUEST FOR FINAL WAIVER OF OPEN COSTSCC-DC-090 (Rev. 12/2018) I, , request that the court grant a final waiver of opencosts. I am unable to pay the final open court fees and costs in this matter because of poverty.Name of Party Affidavit of Income. (Complete this section only if the section above does not apply to you)I respectfully submit that:1. There are family members living in my household, including myself. (Do not includerenters or temporary guests).2. The total gross household income (before taxes) is $ (total incomeearned by all persons in the household) per WEEK MONTH YEAR.3. The gross household income (before taxes) is from the following sources (list amounts before taxes)per WEEK MONTH YEAR:$$$$$$$$$ 4. I own the following property. (Do not list your home, one vehicle, and/or personal items in yourhome):NONE$$$$$Value:Balance:Value:Value:Value: Affidavit of Continuing EligibilityThis court waived the prepaid costs in this matter; and:There has been no material change in my financial situation since the waiver of prepaid costs was granted.NumberWages.......................................................................................................Commissions/Bonuses.............................................................................Social Security/SSI..................................................................................Retirement Income...................................................................................Unemployment Insurance........................................................................Temporary Cash Assistance.....................................................................Alimony/Spousal Support........................................................................Rent received from tenants...................................................................... Any Other Income (Do not include food stamps/SNAP).........................Real estate other than principal home........................................Other vehicles including boats...................................................Bank Accounts...........................................................................Stocks or other securities............................................................Other property (describe):vs.IN THE MATTER OF:Petitioner/PlaintiffCIRCUIT COURT DISTRICT COURT OF MARYLAND FORLocated at Case No.City/CountyCourt AddressRespondent/Defendant American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3CC-DC-090 (Rev. 12/2018)5. I owe the following debts:6. Other information to demonstrate my inability to prepay the costs:NONE For these reasons, I request a final waiver of open costs. I affirm under the penalties of perjury that what I have said above is true to the best of myknowledge, information, and belief.Attorney NameAddressCity, State, ZipTelephone / FaxDateCERTIFICATE OF SERVICE005E-mail I HEREBY CERTIFY that on , a copy of this Request for Final Waiver of OpenCosts was served by hand delivery mailing first class mail, postage prepaid, to the following parties:DateAddressAddressNameNameSignatureDateParty SignatureParty NameAddressCity, State, ZipTelephone / FaxDateE-mailCredit Card:Car Loan:Other Debt:Amount Owed: $Amount Owed: $Amount Owed: $Monthly Payment: $Monthly Payment: $Monthly Payment: $Attorney SignatureCPF ID No. American LegalNet, Inc. www.FormsWorkFlow.com CC-DC-090 (Rev. 12/2018)Page 3 of 3vs.IN THE MATTER OF:Petitioner/PlaintiffCIRCUIT COURT DISTRICT COURT OF MARYLAND FORLocated at Case No.City/CountyCourt AddressRespondent/Defendant ORDER REGARDING REQUEST FOR FINAL WAIVER OF COSTS UPON CONSIDERATION of the Request for Final Waiver of Costs submitted by , and any further documentation as required or authorized byRule 1-325 or other applicable law,THE COURT FINDS THAT:Other findings:THE COURT ORDERS that the waiver is:GRANTEDDENIEDThe party named above:Meets the financial eligibility guidelines of the Maryland Legal Services Corporation.Does NOT meet the financial eligibility guidelines.The party named above:Is unable by reason of poverty to pay the costs.Is NOT unable by reason of poverty to pay the costs.DateJudge's SignatureName of PartyID Number American LegalNet, Inc. www.FormsWorkFlow.com