12/05 WDNY UNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK (Name of Plaintiff(s) or Petitioner(s)) v. MOTION FOR WAIVER OF ADR FEE AND SUPPORTING AFFIRMATION __________-CV-_________ (Name of Defendant(s) or Respondent(s)) Note: Litigants who have been granted in forma pauperis status need not complete this form. , (print or type your name) am a ______________ (plaintiff or defendant) in the aboveI, entitled case and hereby request that the Court waive my pro rata share of the ADR Neutral’s fee, or some portion thereof. In support of my motion for a waiver, I state that because of my poverty I am unable to pay a pro rata share of the ADR Neutral’s fee and that I believe I am entitled to redress. I further declare that the responses which I have made in this affirmation below are true. 1. No Are you presently employed? Yes My Employer’s Name and Address is: My Gross Monthly Wages are: $ If you are not presently employed, state Your Last Date of Employment: Your Gross Monthly Wages at that time: Is your spouse presently employed? Yes No My Spouse’s Employer’s Name and Address is: My Spouse’s Gross Monthly Wages are $ 2. Have you received any money from any of the following sources within the past twelve months: a. Business, profession or self-employment? Yes No If yes, state source and amount received per month $ b. Rent payments, interest or dividends? Yes No If yes, state source and amount received per month $ c. Pensions, annuities, disability, or life insurance payments? Yes No If yes, state source and amount received per month $ d. Gifts or inheritances? Yes No If yes, state source and amount received per month $ e. Child Support? Yes No If yes, state amount received each month $ f. Government Benefits (Social Security, SSI, Welfare, AFDC, Veterans, etc.)? Yes No If yes, state source and amount received per month $ g. Friends, Relatives or any other source? Yes No If yes, state source and amount received per month $ If you have not received any money from any of the above sources, please explain how you are currently paying your expenses: American LegalNet, Inc. www.FormsWorkflow.com 3. What is your total gross monthly income today: $ 4. How much cash do you have on hand? $ 5. How much money do you have in a checking account(s)? $ 6. How much money do you have in a savings account(s)? $ 7. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household No furnishings and clothing)? Yes If so, describe the property in detail and give an estimated value of the property: If you own property, are you paying off a loan or mortgage on it? Yes If yes, where are you obtaining the money to make such payments: No 8. State your total monthly household expenses: Rent or mortgage $ Food $ Utilities $ All other expenses $ If your monthly expenses exceed the amount of income you listed in # 3 above, please explain how you are paying your expenses: 9. List all of the people who are in your household and state the amount of money each one contributes to household expenses each month (identify minor children only by their initials): 10. List the persons who are dependent upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support (identify minor children only by their initials and their relationship to you): 11. Have you been adjudicated bankrupt within the past ten (10) years? Yes If the answer is yes, please include the court and date of filing No I declare under penalty of perjury that the foregoing is true and correct. Executed on (Date) (Movant’s Signature) American LegalNet, Inc. www.FormsWorkflow.com