COUNTY STATE OF WISCONSIN, CIRCUIT COURT, -vs- For Official Use Petition for Waiver of Filing and Service Fees Affidavit of Indigency and Order Case No. Under oath, I state that because of poverty, I am unable to pay filing and service fees 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 on page 2. Section 1. I currently receive: Medical assistance Relief funded under §59.53(21), Wis. Stats. Supplemental security income Relief funded under public assistance Food stamps 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: has not changed since I became eligible for this program. has My financial situation 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 on page 2 of this form. Subscribed and sworn to before me on I understand that if my financial situation changes, I must notify the court immediately. Signature Notary Public/Court Official Date My commission expires: Address COURT FINDINGS AND ORDER 1. This petition is 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. Any request for waiver of any other fees or costs must be made to the court for consideration and decision. 2. This petition is 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 3. This petition is DENIED because the court finds: the allegation of poverty to be untrue. petitioner is not indigent. petitioner has not stated a meritorious claim, defense, or appeal upon which the court may grant relief: (Brief explanation) BY THE COURT: Original: Clerk of Circuit Court Circuit Court Judge Date CV-410, 01/09 Petition for Waiver of Filing and Service Fees - Affidavit of Indigency and Order §814.29, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Petition for Waiver of Filing and Service Fees - Affidavit of Indigency and Order Page 2 of 2 Case No. Section 2. Complete this section only if you do not qualify under Section 1, or if the instructions for that section require you to complete it. 1. I am am not married. 2. I am am not employed. Name of employer: gross weekly. 3. I earn $ My take-home pay is $ every 2 weeks. per pay period. monthly. twice monthly. from: Unemployment compensation Other: 4. I receive total monthly income of $ Social security Pension Student loans/grants Disability 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: Under age 18 Under age 18 Under age 18 Under age 18 Under age 18 Yes Yes Yes Yes Yes from: 8. The other members of my household have total monthly income of $ Wages Pension Disability Other: Relief funded under public assistance Social security Unemployment compensation Student loans/grants 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: $ $ $ $ $ No No No No No Food stamps Supplemental security income Support/maintenance Monthly Payment: 10. I have the following unusual expenses, other than ordinary living expenses: CV-410, 01/09 Petition for Waiver of Filing and Service Fees - Affidavit of Indigency and Order §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