STATE OF WISCONSIN, CIRCUIT COURT, COUNTY For Official Use Amended Petition for Waiver of Fees and Costs Affidavit of Indigency and Order -vs- Case No. UNDER OATH, I STATE THAT because of poverty, I am unable to pay any filing and service fees or , in this action, proceeding, or appeal, or to give security for those fees, and request waiver of those fees. I am attaching a copy of my pleading in this matter. Complete Section 1 if you receive aid from any of the programs listed. If you do not receive aid, complete Section 2 only. Section 1. I currently receive Supplemental security income. Relief funded under §59.53(21), Wis. Stats. Medical assistance. Food stamps/FoodShare. Relief funded under public assistance. Benefits for veterans under §45.40 (1) or 38 USC 501-562. Legal representation from a civil legal services program or a volunteer attorney program based on indigency. Name of program: Other means-tested public assistance: My financial situation has has not changed since I became eligible for this program. If you checked the “has” box, and such changes would make you ineligible for the program(s) if you applied today, you must complete Section 2. Section 2. 1. I am am not married. 2. I am am not employed. Name of employer: 3. I earn (gross pay) $ weekly. My take-home pay (after taxes and deductions) is $ every 2 weeks. per pay period. twice monthly. monthly. 4. I receive gross monthly income totaling the amount of $ from Pension Social security Unemployment compensation Disability Student loans/grants Other: 5. I have the following cash assets: Savings accounts: $ Checking accounts: $ Cash: $ Money owed me: $ 6. I have the following other assets: Vehicle-Yr./Make: $ Vehicle-Yr./Make: $ Other individual assets valued over $200 each: 7. My household consists of myself and Full name: Full name: Full name: Full name: Full name: Household furnishings: $ Equity in real estate: $ $ others: Relationship to me: Relationship to me: Relationship to me: Relationship to me: Relationship to me: CV-410, 08/11 Petition for Waiver of Fees and Costs - Affidavit of Indigency and Order Under age 18 Under age 18 Under age 18 Under age 18 Under age 18 No No No No No §§757.675(3), 757.69(2m) and 814.29, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 Yes Yes Yes Yes Yes American LegalNet, Inc. www.FormsWorkFlow.com Petition for Waiver of Fees and Costs - Affidavit of Indigency and Order Page 2 of 2 Case No. 8. The other members of my household have gross monthly income totaling the amount of $ Wages Pension Disability Other: Social security Relief funded under public assistance Student loans/grants Unemployment compensation Relief funded under §59.53(21), Wisconsin Statutes 9. I have the following debts: a. Mortgage/Rent b. Auto loan c. Credit cards d. Other: Amount: $ $ $ $ $ from Food stamps/FoodShare Supplemental security income Support/maintenance Monthly Payment: 10. I have the following unusual expenses, other than ordinary living expenses: I understand that if my financial situation changes, I must notify the court immediately. State of County of Subscribed and sworn to before me on  Signature Print or Type Name Notary Public/Court Official Date of Birth Name Printed or Typed My commission/term expires: Address Date THE COURT FINDS AND ORDERS: This petition is 1. GRANTED because the court finds the petitioner is currently indigent. The action may be commenced without payment of filing fees. The sheriff shall serve all necessary documents without payment of service fees. The petitioner may be required to pay filing and services fees if the court later determines the petitioner has the ability to pay. 2. GRANTED for waiver of pay fees if the court later determines the petitioner has the ability to pay. . The petitioner may be required to 3. DENIED because the court finds the petitioner is not indigent, but is currently not able to pay filing or service fees. This action may be filed by the Clerk and all necessary documents may be served by the sheriff without prepayment of fees. Such fees must be paid no later than . 4. DENIED because the court finds petitioner is not indigent. the allegation of poverty to be untrue. petitioner has not stated a meritorious claim, defense, or appeal upon which the court may grant relief: (Brief explanation) THIS IS A FINAL ORDER FOR PURPOSES OF APPEAL IF SIGNED BY A CIRCUIT COURT JUDGE. BY THE COURT: DISTRIBUTION: 1. Original: Clerk of Circuit Court Circuit Court Judge Circuit Court Commissioner Date CV-410, 08/11 Petition for Waiver of Fees and Costs - Affidavit of Indigency and Order §§757.675(3), 757.69(2m) and 814.29, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com