PETITION FOR PROCEEDING IN CIVIL CASE WITHOUT PAYMENT OF FEES OR COSTS Case No. ...................................................................... COMMONWEALTH OF VIRGINIA ..................................................................................................................................... ........................................................................................................... v. [ ] General District Court [ ] Juvenile & Domestic Relations District Court [ ] Circuit Court ..................................................................................................................... The undersigned petitioner(s) request the court to permit the petitioner(s) to sue or defend a civil case in this court without the payment of fees or costs and to have from all officers all needful services and process. In support of the petition, the petitioner(s) state that the following information is true: 1. The undersigned petitioner(s) are Virginia resident(s). 2. The following financial information applies to the petitioner(s): a. Receiving public assistance [ ] No [ ] Yes-See items checked below [ ] Medicaid [ ] Supplemental security income [ ] TANF [ ] Food stamps b. Take-home pay $ ................................... per [ ] week [ ] twice a month c. Other income, if any (specify sources and amounts): [ ] every second week [ ] month ......................................................................................................................................................................................................................................... d. Assets Cash on hand $ ....................................................... Bank accounts $ ......................................................... 3. Other information a. The number of people for whom the petitioner(s) provide support is: b. The number of persons residing with the petitioner(s) is: ............................................................... ............................................................................................. c. Complete if applicable: In custody at ...................................................................................................................................................................................................... ACKNOWLEDGEMENT I understand that the court cannot provide me with legal advice, and that it may be advisable to get advice from a lawyer. ............................................................................................................ _______________________________________________________________ DATE SIGNATURE – PETITIONER ________________________________ SIGNATURE – PETITIONER ........................................................................................................................................................................................................................................................... NAMES OF PETITIONERS ORDER [ ] The petition is granted. [ ] The petition is denied. ...................................................................................................................................................................................... ........................................................................................................................................................................................ .............................................................................................. DATE FORM CC-1414 MASTER 11/06 VA. CODE §§ 16.1-69.48:4; 17.1-606 ______________________________________________________________ JUDGE American LegalNet, Inc. www.FormsWorkflow.com