Page 1 of 3REQUEST FOR WAIVER OF PREPAID COSTSCC-DC-089 (Rev. 12/2018) I, , wish to file a complaint, petition, or other documents whichI have completed and attached. I am unable to prepay the prepaid costs in this matter because of poverty.Name of Party Affidavit of IncomeI 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 income earnedby 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:WagesCommissions/BonusesSocial Security/SSIRetirement IncomeUnemployment InsuranceTemporary Cash AssistanceAlimony/Spousal SupportRent received from tenants Any Other Income (Do not include food stamps/SNAP)$$$$$$$$$ 4. I own the following property. (Do not list your home, one vehicle, and/or personal items in yourhome):NONEReal estate other than principal homeOther vehicles including boatsBank AccountsStocks or other securitiesOther property (describe):$$$$$Value:Balance:Value:Value:Value:Number(Md. Rule 1-325)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-089 (Rev. 12/2018)5. I owe the following debts:6. Other information to demonstrate my inability to prepay the required costs:NONECredit Card:Car Loan:Other Debt: For these reasons, I request a waiver of the prepaid costs. I understand that I may have to pay these costs at the end of the case, unless the court grants afinal waiver of open costs, and that if I want a final waiver of open costs I must request the waiver atthe conclusion of the action in accordance with Maryland Rule 1-325(f)(2)(A).Amount Owed: $Amount Owed: $Amount Owed: $Monthly Payment: $Monthly Payment: $Monthly Payment: $ I affirm under the penalties of perjury that what I have said above is true to the best of myknowledge, information, and belief.Party SignatureParty NameAddressCity, State, Zip Attorney Certification (To be completed by your lawyer, if you are represented).I, , certify that to the best of my knowledge, information, andbelief, there is a good ground for this claim, application, or request for process, and it is not interposed forany improper purpose or delay.Attorney SignatureAttorney NameAddressCity, State, ZipTelephone / FaxDateName of AttorneyOn behalf of:Name of PartyTelephone / FaxE-mailDateE-mailCPF ID No. American LegalNet, Inc. www.FormsWorkFlow.com CC-DC-089 (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 WAIVER OF PREPAID COSTS UPON CONSIDERATION of the Request for Waiver of Prepaid 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:GRANTEDDENIED. You have 10 days from the date of this order to pay the costs. If the unwaived costsare not paid in full within 10 days, the pleading or papers filed will be considered withdrawn.The 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 prepaid costs.Is NOT unable by reason of poverty to pay the prepaid costs.The claim, appeal, application or request for processdoes not appear, on its face, to be frivolous.DOES appear, on its face, to be frivolous.DateJudge's Signature ID NumberName of Party American LegalNet, Inc. www.FormsWorkFlow.com