Page 1 of 3REQUEST FOR WAIVER OF PREPAID COSTS FORASSEMBLING THE RECORD FOR AN APPEALvs.IN THE MATTER OF:Petitioner/PlaintiffCC-DC-091 (Rev. 12/2018)CIRCUIT COURT DISTRICT COURT OF MARYLAND FORLocated at Case No.City/CountyCourt Address I, , request that the trial court grant a waiver ofprepaid costs for assembling the record. I am unable to prepay the prepaid costs in this matter because ofpoverty. Affidavit of Continuing EligibilityI respectfully submit that this court waive the prepaid costs in this matter andRespondent/DefendantName of PartyI will be represented by the following organization on appeal and am financially eligible for theirservices (Attorney signature required below):Maryland Legal AidThe Office of the Public DefenderA lawyer through Maryland legal services provider,Name of Organization/ProgramThe Maryland Legal Services Corporation funds or has otherwise approved that organization toprovide civil legal services on behalf of low-income persons; and/orThere has been no material change in my financial situation since the waiver of prepaid costs wasgranted. 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 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:$$$$$$$$$NumberWagesCommissions/BonusesSocial Security/SSIRetirement IncomeUnemployment InsuranceTemporary Cash AssistanceAlimony/Spousal SupportRent received from tenants Any Other Income (Do not include food stamps/SNAP) American LegalNet, Inc. www.FormsWorkFlow.com CC-DC-091 (Rev. 12/2018) 4. I own the following property. (Do not list your home, one vehicle, and/or personal items in yourhome):5. I owe the following debts:6. Other information to demonstrate my inability to pay the costs:NONE$$$$$Value:Balance:Value:Value:Value:NONECredit Card:Car Loan:Other Debt:For these reasons, I request the trial court grant a waiver of prepaid costs associated with assembling therecord.Amount Owed: $Amount Owed: $Amount Owed: $Monthly Payment: $Monthly Payment: $Monthly Payment: $ I understand that I may have to pay these costs at the end of the case, unless the court grants a finalwaiver of open costs, and that if I want a final waiver of open costs I must request the waiver at theconclusion of the action. I affirm under the penalties of perjury that what I have said above is true to the best of my knowledge,information, and belief.Party SignatureParty NameAddressCity, State, ZipTelephone / FaxDatePage 2 of 3Real estate other than principal homeOther vehicles including boatsBank accountsStocks or other securitiesOther property (describe):E-mail Attorney Certification (To be completed by your lawyer, if you are represented).I, , certify that to the best of my knowledge, information, and belief,there is good ground to support the appeal, and it is not interposed for any improper purpose or delay.Name of AttorneyAttorney SignatureAttorney NameAddressCity, State, ZipTelephone / FaxDateE-mail CPF ID No. American LegalNet, Inc. www.FormsWorkFlow.com CC-DC-091 (Rev. 12/2018)Page 3 of 3 UPON CONSIDERATION of the Request for Waiver of Prepaid Costs for Assembling the Recordsubmitted by , and any further documentation as requiredor authorized by Rule 1-325 or other applicable law,THE COURT FINDS THAT:The party named above received a waiver of prepaid costs in accordance with Rule 1-325(d), willbe represented in the appeal by an eligible attorney under that section, and the attorney hascertified that the appeal is meritorious and that the party remains eligible for representation inaccordance with Rule 1-325(d).The party named above received a waiver of prepaid costs in accordance with Rule 1-325(e), andthere has been no material change in the party's financial situation since the waiver was granted.Other findings:THE COURT ORDERS that the waiver is:GRANTED The prepaid costs associated with assembling the record are hereby waived.DENIED. You have 10 days from the date of this order to pay the costs associated withassembling the record. If the unwaived costs are not paid in full within 10 days, the appeal will beconsidered withdrawn.In the District Court, this includes a waiver of the costs of preparing a transcript, if requiredby Rule 7-113.Name of PartyThe 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 prepaid costs.DateJudge's Signature ID NumberORDER REGARDING REQUEST FOR WAIVER OFPREPAID COSTS FOR ASSEMBLING THE RECORDCIRCUIT COURT DISTRICT COURT OF MARYLAND FORLocated at Case No.City/CountyCourt Address American LegalNet, Inc. www.FormsWorkFlow.com