APPLICATION FOR WAIVER OF FAMILY COURT SERVICES FEE Your Name:_______________________________ Name of other parent _______________________ 1. I am paid weekly every 2 weeks two times per month once per month (circle one). Case Number: ________________ 2. My gross paycheck (before taxes or other deductions) from employment $_____________. 3. I receive other monthly income totaling $__________________ from pension, disability, social security, educational grants, interest and dividends or unemployment compensation. 4. I receive child support and/or maintenance in the amount of $__________ . weekly every two weeks two times per month monthly (circle one) 5. I have cash assets in savings accounts, checking accounts or cash on hand in the total amount of $_____________. Complete Schedule A on back of form. 6. I have other assets over $500 in value (stocks, bonds, automobile(s), retirement accounts, security, ownership in business). Complete Schedule B on back of form. 7. I have equity in real estate in the amount of $______________. Equity is determined by taking the value of your real estate and subtracting the amount that you owe on that real estate. 8. The other party to this case and I are/are not still married. (Circle one). Our combined gross income is approximately $__________ per month. (List combined income only if divorce is not finalized). 9. My household consists of myself and ________ others. Complete Schedule C on back of form. 10. The other members of my household have monthly income totaling $ _____________. 11. I pay child support or maintenance in the amount of $___________. weekly every two weeks two times per month monthly (circle one) 12. I pay day care/child care expenses in the amount of $___________. weekly every two weeks two times per month monthly (circle one) You must attach copies of your 3 most recent pay stubs from employment and a copy of your most recent tax return, with this application in order for it to be considered. If you are remarried, you must also attach copies of pay stubs and copies of the most recent tax return for your spouse, if you reside in the same household. Under penalty of perjury, I swear that this is a true statement. I understand that if my financial situation changes, I must notify the court immediately. ____________________________________ Signature ______________________ Date Subscribed & sworn to before me on _______________________ Notary Public / Court Official My commission expires: __________________________ (Last modified 7-1-13) American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE A: CASH ASSETS Description of asset (e.g. savings, checking, money market) Amount of asset SCHEDULE B: OTHER ASSETS Description of asset (e.g. stocks, bonds, automobiles, retirement accounts) Approximate value of asset Amount of loan, if any, against asset SCHEDULE C: HOUSEHOLD Name of person Relationship to applicant (e.g., spouse, child, stepchild) If child/stepchild, under age 18? Yes No Yes Yes Yes Yes Yes No No No No No % of time in household American LegalNet, Inc. www.FormsWorkFlow.com