en-USAAA Case No: en-USYour name: en-USGross pay or wages: $ en-US per en-US week/ en-US month / en-US year (select one)en-USGross pay is the amount of money you earn before taxes are taken out.en-USTake-home pay or wages: $ en-US per en-US week/ en-US month / en-US year (select one)en-USTake-home pay is the amount of money you receive after taxes are taken out.en-USNumber of people in your household: en-USNumber of adults (over 18 years old) in your household: en-USNumber of children (18 years old or under) in your household: en-USHousehold means the number of people you can claim as a dependent on your income tax returns, including you and your spouse en-USor partner (if you are married). en-USAddress: en-USCity: en-USState: en-USZip Code: en-USEmployer: en-USEmployer address: en-USCity: en-USState: en-USZip Code: en-USPrior Applications for Fee Waiversen-USWithin the last two years, have you requested the AAA or a court waive your fees and costs? en-US Yes en-US Noen-USAAA? en-US Yes en-US No What court(s)? en-USWhat was the outcome? en-USAdditional Incomeen-USBonuses (including frequency): en-USAmount and types of government assistance: en-USBusiness, profession or other self-employment income: en-USRent payments received, interest, or dividends: en-USPension, annuity or life insurance payments received: en-USA primary factor used by the AAA in approving fee waivers is the federal poverty guidelines; absent other supporting en-USinformation requested in this af037davit, individuals whose gross monthly income exceeds 300% of the federal poverty en-USguidelines will not likely receive approval to have the AAA222s fees waived. American LegalNet, Inc. www.FormsWorkFlow.com en-USDisability, or workers compensation payments: en-USOther 037nancial support or income, (state source and amount you receive, and frequency): en-USAssetsen-USTotal cash and/or checking accounts: $ en-USTotal in CDs and savings accounts: $ en-USValue of liquid investments (mutual funds, ETFs, etc.): en-USValue of other investments (stocks, bonds, trusts): en-USAttorney222s fees: $ en-USMy representative is working on a contingency basis or pro bono en-US Yes en-US Noen-USAny other factors you would like us to consider (do NOT attach bank statements, tax returns, or any other documents):en-USI am a party to this case and declare that I do not have the 037nancial means suf037cient to pay the AAA222s administrative fees. I understand en-USthat any hardship waiver, if granted, does not affect my separate obligation to pay arbitrator compensation. I hereby swear and af037rm en-USthat the foregoing is a true and correct statement of my 037nancial condition and my ability to pay.en-USSignature en-USPlease email completed form to en-USAAAfeewaivers@adr.orgen-US.en-US en-USOr mail to: en-USAmerican Arbitration Associationen-USAttn: Fee Waiversen-US1301 Atwood Avenueen-USJohnston RI, 02919 American LegalNet, Inc. www.FormsWorkFlow.com