Mt and Decl for Civil Fee Waiver (MTAF) - Page 1 of 5 WPF GR 34.0100 (05/2014) 226 GR 34 SUPERIOR Court of Washington For BENTON & FRANKLIN COUNTY Petitioner/Plaintiff, vs. Respondent/Defendant. No. Motion and Declaration For Waiver of Civil Fees and Surcharges (MTAF) I. Motion 1.1 I am the petitioner/plaintiff respondent/defendant in this action. 1.2 I am asking for a waiver of fees and surcharges under GR 34. II. Basis for Motion 2.1. GR 34 allows the court to waive 223fees or surcharges the payment of which is a condition precedent to a litigant's ability to secure access to judicial relief224 for a person who is indigent. As outlined below, I am indigent. Dated: Signature of Requesting Party Print or Type Name III. Declaration I declare that, 3.1 I cannot afford to meet my necessary household living expenses and pay the fees and surcharges imposed by the court. Please see the attached Financial Statement, which I incorporate as part of this declaration. American LegalNet, Inc. www.FormsWorkFlow.com Mt and Decl for Civil Fee Waiver (MTAF) - Page 2 of 5 WPF GR 34.0100 (05/2014) 226 GR 34 3.2 In addition to the information in the financial statement I would like the court to consider the following: . (Check if applies.) I filed this motion by mail. I enclosed a self-addressed stamped envelope with the motion so that I can receive a copy of the order once it is signed. I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (city) , (state) on (date) . Signature Print or Type Name American LegalNet, Inc. www.FormsWorkFlow.com Mt and Decl for Civil Fee Waiver (MTAF) - Page 3 of 5 WPF GR 34.0100 (05/2014) 226 GR 34 SUPERIOR Court of Washington For BENTON & FRANKLIN COUNTY Petitioner/Plaintiff, vs. Respondent/Defendant. No. Order Re Waiver of Civil Fees and Surcharges Granted (ORPRFP) Denied (ORDYMT) Clerk222s Action Required 3.1 I. Basis The court received the motion to waive fees and surcharges filed by or on behalf of the petitioner/plaintiff respondent/defendant. II. Findings The Court reviewed the motion and supporting declaration(s). Based on the declaration(s) and any relevant records and files, the Court finds: 2.1 The moving party is indigent based on the following: He or she: is represented by a qualified legal aid provider that screened and found the applicant eligible for free civil legal aid services; and/or receives benefits from one or more needs-based, means-tested assistance programs; and/or has household income at or below 125% of the federal poverty guideline; and/or has household income above 125% of the federal poverty guideline but cannot meet basic household living expenses and pay the fees and/or surcharges; and/or other: . American LegalNet, Inc. www.FormsWorkFlow.com Mt and Decl for Civil Fee Waiver (MTAF) - Page 4 of 5 WPF GR 34.0100 (05/2014) 226 GR 34 2.2 The moving party is not indigent. 2.3 Other: . III. Order Based on the findings the court orders: 3.1 The motion is granted, and all fees and surcharges the payment of which is a condition precedent to the moving party222s ability to secure access to judicial relief are waived. other: . 3.2 The motion is denied. Dated: Judge/Commissioner Presented by: Signature of Party or Lawyer/WSBA No. Print or Type Name Date American LegalNet, Inc. www.FormsWorkFlow.com Mt and Decl for Civil Fee Waiver (MTAF) - Page 5 of 5 WPF GR 34.0100 (05/2014) 226 GR 34 Case Name: Case Number: Financial Statement (Attachment) 1. My name is: 2. [ ] I provide support to people who live with me: How many? Age(s): 3. My Monthly Income : 6. My Monthly Household Expenses : Employed [ ] Unemployed [ ] Rent/Mortgage: $ Employer222s Name: Food/Household Supplies: $ Gross pay per month (salary or hourly pay): $ Utilities: $ Take home pay per month: $ Transportation: $ 4. Other Sources of Income Per Month in my Household: Ordered Maintenance actually paid: $ Source: SPOUSE/PARTNER $ Ordered Child Support actually paid: $ Source: RESPONDENT $ Clothing: $ Source: $ Child Care: $ Source: $ Education Expenses: $ Sub-Total: $ Insurance (car, health): $ [ ] I receive food stamps. Medical Expenses: $ Total Income, lines 3 (take home pay) and 4 : $ Sub-Total: $ 5. My Household Assets : 7. My Other Monthly Household Expenses : Cash on hand: $ $ Checking Account Balance: $ $ Savings Account Balance: $ $ Auto #1 (Value less loan): $ $ Auto #2 (Value less loan): $ Sub-Total: $ Home (Value less mortgage): $ 8. My Other Debts with Monthly Payments : Other: $ $ /mo Other: $ $ /mo Other: $ $ /mo Other: $ $ /mo Other: $ Sub-Total: $ Total Household Assets: $ Total Household Expenses and Debts, lines 6, 7, and 8 : $ Date: Signature: American LegalNet, Inc. www.FormsWorkFlow.com