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Appendix D
Instructions and Form for Application to Have Court Fees Waived

• Instructions for the completion of Form 982(a)(17): Application for Waiver of Court Fees and Costs
• Form 982(a)(17): Application for Waiver of Court Fees and Costs (PDF format)
• Instructions for the Completion of Form 982(a)(18): Order on Application for Waiver of Court Fees and Costs
• Form 982(a)(18): Order on Application for Waiver of Court Fees and Costs (PDF format)

Instructions for the completion of Form 982(a)(17): Application for Waiver of Court Fees and Costs

Persons who cannot afford to pay court costs and fees may be able to file their papers without having to pay if the court agrees to "waive" your fee. If you are currently receiving financial assistance under SSI and SSP (the Supplemental Security Income and State Supplemental Payments Program), AFDC (Aid to Families with Dependent Children), or TANF (Temporary Aid to Needy Families), Food Stamps, or General Assistance, you automatically qualify for a waiver. You may also qualify for a fee waiver if your gross monthly income is less than a certain amount. File this form if you want the court to let you file your papers without having to pay for court expenses.

In the first three blocks, print your name, and telephone number, the name and address of the court that has jurisdiction, the names of the plaintiff (your name) and the name of the defendant (the name of the county and/or employees listed on your claim).

Complete the rest of the form as follows:

• #1: Print your current address
• #2: Print the date you were born.
• #3: Print your occupation and employer.
• #4: Check the first box if you are receiving any kind of public assistance. Then check any of the other boxes which describes the type of assistance you are receiving:
  • Check box 4a if you receive SSI or SSP
  • Check box 4b if you receive AFDC (now called TANF)
  • Check box 4c if you receive Food Stamps
  • Check box 4d if you receive County Relief, General Relief or General Assistance.
• #5: If you checked box #4, you must check an complete either box (a) or box (b). You cannot check both boxes.
  • Box 5a requires you to provide your social security number.
  • Box 5b requires you to attach documents to verify that you receive the benefits you checked in #4. A chart describing the types of documents that can be used for verification is included in this appendix.

  NOTE: If you checked box #4, and completed either box 5a or 5b, you are not required to fill out the rest of this form. Simply go to the bottom of the front page and print today’s date after the word "Date." Then print your name on the dotted line provided on the left side of the page and sign your name on the line labeled "signature" on the right side of the page.

  If you did not check box #4, you must complete the rest of the form.

• #6: In order to qualify to have your court fees and costs waived when you are not receiving public assistance, you must meet certain income guidelines. These guidelines take into consideration your monthly family income and the number of persons in your family. A chart of income guidelines is provided in this appendix. Check with the court clerk’s office to see if you qualify under the guidelines.

  If you find that you qualify under the guidelines, check box #6 and skip #7. You must complete #8 and #9 on the back of the form, and date, print and sign the form at the bottom of the first page.

• #7: Check this box if your income does not qualify under the guidelines in #6 and you are still unable to pay costs and fees because of common necessary living expenses you must pay each month. You must now complete each item on the back of the form.
• #8: Check this box if your income fluctuates from month to month. That is, you make much more (or less) money one month than the next. Add together the income you receive for each moth during the year to get a total figure. Divide the total by 12. This gives you your average monthly income figure for use in item 9.
• #9a: Print the figure you calculated in #8, or your gross monthly income.
• #9b: On lines (1)-(4), list the type and amount of each of your payroll deductions. Add the figures together and print the amount on the "total payroll deduction" line.
• #9c: Take the figure in #9a and subtract from it the amount on the "total payroll deduction" line in #6b. Print this amount here.
• #9d: If you receive any other money in addition to your gross monthly income, print the source an amount of the money received. Print the total amount on the line provided.
• #9e: Add the amount listed in #9c to the amount listed in #6d. Print the figure here.
• #9f: Enter the total number of persons living with you that depend on your income for support.
• #9g: Print your spouse’s gross monthly income.
• #9h: Print your spouse’s occupation.
• #10a: Check this box if you are unable to pay any of the court fees and costs.
• #10b: Check this box if you can pay some of the court expenses. List those fees or costs you are able to pay.
• #11: List the dollar amount of each of your monthly living expenses in items 11a through 11m.
• #11n: Add together the amounts of living expenses in 11a through 11m. Print the total here.
• #12: In this item, a through e, you must list the type and value of all property that you own. The types of properties you must list are specified on the form.
• #13: If there are other factors that cause you to be unable to pay court costs and fees, such as "unusual medical needs, expenses for recent family emergencies, or other unusual expenses," list them here. If you need more space, use another sheet of paper and label it "Attachment 13."

IMPORTANT WARNING: If during the course of your proceeding you become able to pay court fees or costs, you must inform the court that you are now able to pay.

Form 982(a)(17): Application for Waiver of Court Fees and Costs (PDF format)
Note: Viewing this form requires Acrobat Reader, which is free and available online. Download Acrobat Reader

Instructions for the Completion of Form 982(a)(18): Order on Application for Waiver of Court Fees and Costs

This form must be filed along with form 982(a)(17): Application for Waiver of Court Fees and Costs. Once the court has reviewed your application and decides to waive your fees and costs, the judge will sign this form allowing you to proceed without paying court expenses.

Complete the caption on page one exactly the same as you did for form 982(a)(17), the Application for Waiver of Court Fees and Costs.

Leave the rest of the page blank and go to page two.

In the blank area below the "Clerks Certificate of Mailing," print your full and complete name and address.

The court will complete the rest of the form.

Form 982(a)(18): Order on Application for Waiver of Court Fees and Costs (PDF format)
Note: Viewing this form requires Acrobat Reader, which is free and available online. Download Acrobat Reader