Plaintiff222s/Petitioner222s name vDefendant222s/Respondent222s namePlaintiff222s/Petitioner222s attorney, and bar no.Defendant222s/Respondent222s attorney and bar no. Probate In the matter of en-US en-USInstructions:en-US Complete the form and file it with the clerk. After you receive a decision on your request, you en-USmust serve your request and the decision on the other party.en-USI request a waiver of my filing fees for the following reason: en-US(Check 1, 2, or 3) � 1. � I receive the following type(s) of public assistance because of indigence: � � Food Assistance Program through the State of Michigan (also known as FAP or SNAP) � � Medicaid (including Healthy Michigan, CHIP, and ESO) � � Family Independence Program through the State of Michigan (also known as FIP or TANF) � � Women, Infants, and Children benefits (WIC) � � Supplemental Security Income through the federal government (SSI) � � Other means-tested public assistance: en-US � My public assistance case number(s) (if any) is en-USWrite 223none224 if no case number. Do not write your SSN. en-US . � 2. � I am represented by a legal services program or I receive assistance from a law school clinic because � of indigence. The name of the legal services program or law school clinic is � en-US en-US . � 3. � I am unable to pay the fees and I did not check item 1 or 2. � My gross household income is $ en-US en-US every en-USWeek/Two weeks/Month/Year . � � The number of people in my household is en-US en-US . � My source of income is en-US en-US . � en-USList assets and their worth, such as bank accounts. If you need more space, attach a separate sheet. � � en-USList obligations and how much you pay, such as rent or other debts. If you need more space, attach a separate sheet.en-USI declare under the penalties of perjury that this request has been examined by me and that its contents en-USare true to the best of my information, knowledge, and belief. en-USDate � en-USSignature � FOR CLERK USE ONLY: en-USPayment of filing fees is waived. en-US en-USDate � en-USSignature of court clerk American LegalNet, Inc. www.FormsWorkFlow.com Case No. en-USIT IS ORDERED: � 1. Payment of filing fees is waived because: � � a. � Your gross household income is under 125% of the federal poverty guidelines. � � b. � Your gross household income is above 125% of the federal poverty guidelines, but payment of � the fees would constitute a financial hardship for you. � � c. � Other: � If you become able to pay the fees before this case is resolved, you must notify the court. � 2. � The fee waiver request is denied because: � � a. � Your gross household income is above 125% of the federal poverty guidelines and payment of � the fees would not constitute a financial hardship for you. � � b. � Other: en-USDate � Judge � Bar no. en-USORDER American LegalNet, Inc. www.FormsWorkFlow.com