UNITED STATES TAX COURT _____________________________, Petitioner (your name) APPLICATION FOR WAIVER OF FILING FEE AND AFFIDAVIT v. COMMISSIONER OF INTERNAL REVENUE, Respondent Docket No: I, _________________________________________, declare that I am the petitioner in the above-entitled proceeding; that in support of my request for waiver of the filing fee, I declare that I am unable to make such payment. In support of this application, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated: G YES G NO (If “No,” go to Part 2) If “Yes,” state the place of your incarceration ____________________________________________ Are you employed at the institution? _______ Do you receive any payment from the institution?______ Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’ transactions. 2. Are you currently employed? G YES G NO a. If the answer is “Yes,” state the amount of your take-home salary or wages and pay period and give the name and address of your employer. b. If the answer is “No,” state the date of your last employment, the amount of your take-home salary or wages and pay period and the name and address of your last employer. 3. In the past 12 twelve months have your received any money from any of the following sources? a. b. c. d. e. f. Business, profession or other self-employment Rent payments, interest or dividends Pensions, annuities or life insurance payments Disability or workers compensation payments Gifts or inheritances Any other sources Page 1 of 2 G YES G YES G YES G YES G YES G YES G NO G NO G NO G NO G NO G NO American LegalNet, Inc. www.FormsWorkflow.com If the answer to any of the above is “Yes,” describe each source of money and state the amount received and what you expect you will continue to receive. 4. Do you have any cash or checking or savings accounts? [ ] YES [ ] NO If "Yes," state the total amount. ____________________ 5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other thing of value? [ ] YES [ ] NO If "Yes," describe the property and state its value. 6. List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support. 7. Additional information (if any). I declare under penalty of perjury that the above information is true and correct. _____________________________ ____________________________________________________ Date Signature of Applicant Return the completed application to: Clerk's Office, Petitions United States Tax Court 400 Second Street, NW Washington, DC 20217 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com