Instructions for Fee Waiver Form: 1) After you have completed the fee waiver form, take it to a notary public - the form must be notarized. NOTE: Make sure your phone number is at the top of the first page, in case the Family Court Commissioner's office has a question. 2) Take the form to the Family Court Commissioner (in the Justice Center) for her review. If you need to mail the form, the address is: Outagamie County Justice Center, Attn. Family Court Commissioner, 320 S. Walnut Street, Appleton, WI 54911. The telephone number is (920) 832-5057. Make sure you follow up on your waiver form once it's been sent in! 3) If you are dropping the form off, you may wait for her to review it if she is not in a hearing. If you leave the waiver at her office for review, you should check back the follow day. (The Family Court Commissioner office does not follow up or return waiver forms.) 4) She will either indicate on the form that you do not qualify for a waiver of fees, or state the amount she has waived your fees to. Payment is then made at the Clerk of Courts (take a copy of waiver with you). NOTE: WAIVER VOID 90 DAYS AFTER SIGNED BY COURT. American LegalNet, Inc. www.FormsWorkFlow.com PHONE: _____________ STATE OF WISCONSIN CIRCUIT COURT FAMILY COURT BRANCH OUTAGAMIE COUNTY __________________________________________________________________________________________ Petitioner: ___________________________ Address: ___________________________ ___________________________ Request for Waiver of Family Court Mediation Fees -vsRespondent: ___________________________ Case No. _____________ Address: ___________________________ ___________________________ ___________________________________________________________________________ AFFIDAVIT ___________________________________________________________________________ Under oath I swear or affirm that: 1. I am requesting Family Court Program services for: __________ Mediation ________ Court Ordered Study 2. Because of my poverty, I am unable to pay the Family Court Program fee. 3. I have no source of income except (i.e., wages, job, child support, unemployment compensation): ________________________________________________________ _____________________________________________________________________ 4. My gross monthly income from all sources is _________________. (Attach wage statements for last 8 weeks) _____________________________________________________________________ 5. I own no property of value except: _________________________________________ _____________________________________________________________________ 6. I live with (please name persons and their relationship to you): __________________ _____________________________________________________________________ _____________________________________________________________________ 7. There is no other source of income in my household except (list monthly income and source of income of each member of your household.) If you are unable to obtain this information, your attached financial disclosure must contain only those expenses for which you are responsible. For instance, if someone else pays the rent, do not put it down as an expense. __________________________________________________________ ______________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 8. I have not requested any other waiver of Family Court Program fees except: _________ ______________________________________________________________________ 9. The attached financial disclosure statement is true and correct to the best of my knowledge. __________________________ Print Name __________________________ Signature Subscribed and sworn to before me this ____ day of _________________, 20_____. ___________________________________ Notary Public, State of Wisconsin My commission expires _______________ ___________________________________________________________________________ ORDER ___________________________________________________________________________ ______ The above request for waiver of Family Court Program fees is denied. OR ______ The above request for waiver of Family Court Program fees is partially approved. __________________________ must pay $_____________. IT IS ORDERED that the Mediation/Study may be commenced immediately. Services shall be provided upon payment of the requested fee. IT IS FURTHER ORDERED that if the Court subsequently determines it is appropriate to recover fees for the services pursuant to Section 814.615, either or both of the parties to this action may be ordered to pay these fees at the conclusion of the action. Dated this ____ day of ______________, 20____. BY THE COURT: ________________________________________ Family Court Commissioner American LegalNet, Inc. www.FormsWorkFlow.com STATE OF WISCONSIN FAMILY COURT BRANCH OUTAGAMIE COUNTY FAMILY COURT COMMISSIONER ____________________________________________________________________________________________________________________ In Re the Marriage/Paternity of: __________________________________, (Petitioner) (Joint Petitioners) FINANCIAL DISCLOSURE -and- Case No. ______________________ __________________________________, (Respondent) -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------NOTE: This statement must be filed with the Family Court Commissioner before or at the time of the hearing. Failure by either party to complete, present, and file this form as required will authorize the Court or Hearing Officer to accept the statement of the other party as the basis for its decision. Any false statement made hereon shall subject you to the penalty for perjury and may be considered a fraud upon the Court. Husband: ___________________________________________________ Address: ____________________________________________________ ____________________________________________________________ Soc. Sec. No.: ________________________________________________ Birthdate: ___________________________________________________ Employer: ___________________________________________________ Occupation: _________________________________________________ Wife: ___________________________________________________ Address: _______________________________________________ _______________________________________________________ Soc. Sec. No.: ___________________________________________ Birthdate: ______________________________________________ Employer: ______________________________________________ Occupation: ____________________________________________ Children: Date of Birth: Age: With whom are children living: ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ I. INCOME (Attach copies of wage statements from your last eight weeks earnings) Husband A. GROSS MONTHLY INCOME: Employment: (Multiply weekly Income by 4.3 and bi-weekly income by 2.15) ______________________ Other: (AFDC, Social Security, Pensions, Disability, ______________________ Unemployment, Interest, Dividends, Rents, Child ______________________ Support from prior marriage, etc.) (Please circle ______________________ source of income.) TOTAL ______________________ B. MONTHLY DEDUCTIONS Taxes Social Security Insurance Union Dues Retirement Credit Union Others Wife ______________________ ______________________ ______________________ ______________________ ______________________ NET MONTHLY INCOME (Subtract Total B from Total A) ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ TOTAL ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ II. MONTHLY EXPENSES Rent or Mortgage (taxes and insurance) Food Utilities Telephone Clothing Laundry Medical Dental Insurance (exclude payroll deductions) Child Care Auto Expense (gas, insurance, etc.) Auto Payments Debts (enter total from III Debts) Miscellaneous TOTAL American LegalNet, Inc. www.FormsWorkFlow.com III. DEBTS Creditor Purposes Original Amount Balance Monthly Payment ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ IV. ASSETS A. REAL ESTATE (If space is insufficient, attach separate schedule. Address Appraised Value Mortgage or Lien Net Value ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ B. MOTOR VEHICLES Type Present Value Mortgage or Lien Who Uses ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ C. CASH AND DEPOSIT ACCOUNTS Bank or Savings & Loan Type Amount ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ D. LIFE INSURANCE Company Premiums Face Amount Beneficiaries Type/Policy Cash Value ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ E. RETIREMENT ANNUITIES OR PROFIT SHARING ACCOUNTS F. STOCKS & SECURITIES (List name, number of shares and value.) G. OTHER ASSETS: (Include valuable collections such as coins, stamps, guns sporting and other equipment, mortgages or notes receivable, interests in Trusts, wills, contract rights, judgments, livestock and pets.) H. HOUSEHOLD FURNITURE: FURNISHINGS & APPLICANCES – PRESENT VALUE __________________________________________. __________________________ Signature Subscribed and sworn to before me this ____ day of _________________, 20_____. ___________________________________ Notary Public, State of Wisconsin My commission expires _______________ American LegalNet, Inc. www.FormsWorkFlow.com