Court Filing Fee Indigency Waiver Form

Applicant's Full Name

First NameLast Name

Contact Information (Phone Number)

Please enter a valid phone number.Format: (000) 000-0000.

Contact Information (Email Address)

example@example.com

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Case Number (if known)

Type of Case

Number of People in Your Household (including yourself)

Current Employment Status

Monthly Income (Total for Household)

Sources of Income (check all that apply)

Do you have any assets (e.g., home, car, savings)?

If yes, please describe your assets and their approximate value:

Monthly Expenses (Total for Household)

List all dependents (names and ages)

Applicant's Signature