Fill and Sign the Cv 067 Rev 0313 Application Proceed Wo Fee Form

STATE OF MAINE SUPERIOR COURT DISTRICT COURT , ss Location Docket No. Docket No. Plaintiff APPLICATION OF PLAINTIFF DEFENDANT v. TO PROCEED WITHOUT PAYMENT OF FEES Defendant M.R. Civ. P. 91 I am without funds to pay the filing fee, service costs, mediation fee, jury fee appeal fee based on the information in my attached affidavit. I am brin ging this action in good faith. I agree to pay any fees or costs that m ay be waived if at any time during this action I am able t o do so or if I receive a monetary settlement or am deemed to be the prevailing party and receive costs. I request that ser vice costs be paid without first attempting service by mail because : Date: (Signature of party) Address: Telephone: ORDER 1. The court has re viewed the proposed pleadings. It appears that the applicant is proceedi ng in good faith and is without sufficient funds to pay certain fees or cost s. It is ORDERED that: the filing fee is waived. the applicant's obligation to pay any part of th e mediation fee is waived. The mediation fee shall be fully paid by the opposing party unless the opposing party also obtains a waiver from the court. If the opposing party does not pay the mediation fee or obtain a waiver within 14 days from the date of this Order, mediation may be scheduled at the request of the applicant and a decision on the opposing party's obligation to pay the mediation fee shall be made by further order of the court. the service costs shall be paid as an e xpense of administration. The applicant must contact the appropriate agency directly to arrange for service of the motion or complaint . The applicant is to attempt service by mail with ack nowledgement. If such service is unsuccessful, service by deputy or by registered mail may be authorized on motion of the applicant, a ccompanied by an affidavit describing the attempted service by mail with acknowledgement, and aft er such hearing as may be necessary. Service by Alternate Means will not be approved except on specific motion. the jury fee is waived. Other 2. The court finds the applicant has the ability to pay all or part of the fees. It is ORDERED that the applicant pay $ toward t he Filing Fee , Mediation Fee , Service costs , and/or Jury fee , as follows: $ each (week)(month) beginning . 3. The decision on whether to waive or require reimburs ement of the Filing Fee , Mediation Fee , Service costs , and/or Jury fee is reserved and shall be made by further order of the court. 4. The application is DENIED. If the application seeks a waiver by Plaintiff of the filing fee and Plaintiff fails to pay the filing fee within 7 days of this Order, the action shall be dismissed without prejudice. 5. If the applicant obtains a monetary settlement or is deemed to be the prevailing party , fees or costs waived pursuant to this Order may be taxed as costs against the opposing party in favor of the State. This order is incorporated into the docket by reference at the specific direction of the co urt. Date: CV-067, Rev . 03/13 Judge / Justice / Magistrate