Fill and Sign the Circuit Court for Case No City or County Form

Circuit Court for _____________Case No._______ City or County NameNameStreet AddressApt. # vs.Street AddressApt. #( )( ) CityStateZip CodeArea CodeTelephoneCityStateZip CodeArea CodeTelephonePlaintiffDefendant MOTION FOR WAIVER OF PREPAYMENT OF FILING FEES AND OTHER COURT COSTS (Dom.Rel. 32) I, __________________ , representing myself, state that: My name 1.I wish to file the form(s) entitled __________________, Name(s) of Forms which I have completed and attached. 2.I am currently unable to prepay filing fees and other court costs because of poverty. 3.The answers to the following questions are true: (a)Do you have any money? ____ How much? ___Where? _____ (b) Are you employed? _______ Where? ______________ Position __________________________ (c)Are you self-employed? _____Doing what? ______________ (d)What is your rate of pay? ______________________ (e)Do you own an automobile? ___ Make ______ Year? _______ Is is paid for? ____ How much do you owe?______ To whom? _____ (f)Do you owe any money to others? _____ How much? _____________ To whom? _________________________________ (g)Do you own real estate? ______ Value? ______ Where? _______ (h)Do you own any other property of any kind? _______ What? _______ (i)Does anyone owe you money? ______ If so, state name, address and amount _______ ________________________________________ (j)Do you receive money from any other source, including disability benefits, _______ investments? ___________ If so, how much? _______________ (k)If married, give the name and address of your wife/husband _____________ _______________________________________________ Does your wife/husband work? _________? Where? _______________ _________________________ Rate of pay ______________ 4. Other facts (if any) concerning my inability to prepay filing fees and other costs are, ____ __________________________________________ _________________________________________________ ___________________________________________________ Dom.Rel. 32 (1/95) Page 1 of 2 FOR THESE REASONS, I request waiver of prepayment of filing fees and othr court costs and any other appropriate relief. I solemnly affirm under the penalties of perjury that the contents of the foregoing paper are true to the best of my knowledge, information, and belief. ___________________________ DateName Circuit Court for ________Case No.______ City or County _________________________________ Name of PlaintiffName of Defendant ORDER (Order to be completed by Court) This Court grants the foregoing Motionn. JudgeDateDom.Rel. 32 (1/95) Page 2 of 2