Original - Court 1st copy - Applicant Approved, SCAO 2nd copy - Opposing party PROBATE OSM CODE: OSF STATE OF MICHIGAN CASE NO. AFFIDAVIT AND ORDER SUSPENSION OF FEES/COSTS JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE Court address Court telephone no. Plaintiff/Petitioner name, address, and telephone no. Defendant/Respondent name, address, and telephone no. v Plaintiff's/Petitioner's attorney, bar no., address, and telephone no. Probate Defendant's/Respondent's attorney, bar no., address, and telephone no. In the matter of NOTE: Requests for waiver/suspension of transcript costs must be made separately by motion. AFFIDAVIT 1. The attached pleading is to be filed with the court by or on behalf of applicant, who is plaintiff/petitioner. , Name defendant/respondent. 2. The applicant is entitled to and asks the court for suspension of fees and costs in the action for the following reason: a. S/he is currently receiving public assistance: $ per Case No.: . b. S/he is unable to pay those fees and costs because of indigency, based on the following facts: INCOME: Employer name and address Length of employment ASSETS: Average gross pay Average net pay per week. month. two weeks. State value of car, home, bank deposits, bonds, stocks, etc. OBLIGATIONS: Itemize monthly rent, installment payments, mortgage payments, child support, etc. 3. (in domestic relations cases only) The applicant is entitled to an order requiring his/her spouse to pay attorney fees. REIMBURSEMENT: It is understood that the court may order the applicant to pay the fees and costs when the reason for their waiver or suspension no longer exists. Affiant signature Subscribed and sworn to before me on My commission expires: , Date Date Signature: County, Michigan. Deputy clerk/Register/Notary public Notary public, State of Michigan, County of (SEE REVERSE SIDE FOR ORDER) MC 20 (6/04) AFFIDAVIT AND ORDER, SUSPENSION OF FEES/COSTS MCR 2.002 American LegalNet, Inc. www.USCourtForms.com CERTIFICATION OF ATTORNEY 1. I have reviewed the affidavit of indigency, and I certify that its contents are true to the best of my information, knowledge, and belief. 2. I will bring to the court's attention the matter of suspended costs and fees and the availability of funds to pay them before any disposition is entered. I will report at that time any changes in the information contained in the affidavit of indigency or any other information regarding the affiant's financial status or alterations of the fee arrangement. Date Attorney signature Attorney name (type or print) Bar no. CERTIFICATION BY PERSON OTHER THAN PARTY 1. I have personal knowledge of the facts appearing in the affidavit. 2. The person in whose behalf the petition is filed is unable to sign it because of minority: Date of birth other disability: Nature of disability Relationship: Date Affiant signature Affiant name (type or print) Address City, state, zip Telephone no. ORDER IT IS ORDERED: 1. Fees and costs in this action required by law or court rule are waived/suspended until further order of the court. Before any final disposition or discontinuance is entered, the moving party shall bring the fee and costs suspension to the attention of the judge for final disposition. 2. The applicant's spouse shall pay the fees and costs required by law or court rule. 3. This application is denied. Date Judge Bar no. American LegalNet, Inc. www.USCourtForms.com