PETITION FOR PROCEEDING IN CIVIL CASE WITHOUT PAYMENT OF FEES OR COSTS COMMONWEALTH OF VIRGINIA Case No.: ...................................................................... General District Court Juvenile & Domestic Relations District Court Circuit Court ......................................................................................... ........................................................................ v. .............................................................................. 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 week twice a month c. Other income, if any (specify sources and amounts): d. Assets Cash on hand $ ....................................................... b. Take-home pay $ .................................... per every second week month ......................................................................................................................................................................................................................................... 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 FORM CC-1414 (MASTER) 06/01 VA. CODE �� 16.1-69.48:4; 17.1-606 American LegalNet, Inc. www.USCourtForms.com