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)*

Monthly Income (Total for Household)*

YesNo

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

Monthly Expenses (Total for Household)*

List all dependents (names and ages)

Applicant's Signature*