Fill and Sign the Fees Due to My Financial Inability to Pay Form

Page 1 of 3 Adm. R. 9(f)(1), Adm. R. 10; TF-920 ( 10/17)(cs) Adm. R. 12(e)(2); Civil R. 90.3 REQUEST FOR EXEMPTION FROM PAYMENT OF FEES, AND ORDER IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) Plaintiff, ) vs. ) ) CASE NO. ) Defendant. ) REQUEST FOR EXEMPTION FROM ) PAYMENT OF FEES, AND ORDER I, , request exemption from payment of the following fees due to my financial inability to pay: F iling fee for a new action or a motion to modify. Admin. Rule 9(f)(1) Note: If you are incarcerated and filing civil litigation against the State of Alaska, do not use this form. You must use form CIV-670, Prisoner Request for Filing Fee Exemption. Copy fees (including exemplified, certified and regular copy fees) . Admin. Rule 9(f)(1) Servicemembers Civil Relief Act attorney fees. Admin. Rule 12(e)(2) FINANCIAL STATEMENT Within the last year, the court exempted me from paying fees in this case due to my inability to pay. The fee exemption was granted on or about the following date: ________________. My financial circumstances have not improved. If you checked this box, skip sections 1 through 5 on this form. I have not been exempted from paying fees in this case or my financial circumstances have improved. If you checked this box, fill out all sections on this form. Phone: Date of Birth: Residence Address: Mailing Address: E-mail Address: Present Employer: (If not now employed, state last employer and date employment ended.) Employer’s Employer’s Address: Phone: 1. INCOME INFORMATION (after taxes, but before other deductions): a. Income during last 12 months: You Your Spouse Wages ......................................... Public Assistance ........................ Unemployment ............................ Other (Specify) TOTAL: b. Current monthly income from all sources: Adm. R. 9(f)(1), Adm. R. 10; Adm. R. 12(e)(2); Civil R. 90.3 Page 2 of 3 TF-920 (10/17)(cs) REQUES T FOR EXEMPTION FROM PAYME NT OF FEE S, AND ORDER 2. FAMILY MONTHLY EXPENSES: Food Rent Utilities Car payments Furniture & Equipment payments Child support or alimony Loans/Time payments TOTAL EXPENSES: 3. FAMILY ASSETS (p resent value): 4.FAMILY DEBTS: Cash on hand or Mortgagein bank LoansLand, bldgs, trailers Credit cardsCars Other (bills, etc.):Snow machines, boats airplanes or other motor vehicles (except cars) TOTAL DEBT: Securities: stocks, bonds, notes Businesses Other Assets: TOTAL ASSETS: 5. DEPENDENTS: Name Age Relationship I swear or affirm that this financial statement is true. I understand that if I give false information in the financial statement, I may be prosecuted for perjury. Date Signature of Plaintiff/Defendant Subscribed and sworn to or affirmed before me at , Alaska on . (date) (SEAL) Notary Public/Judge/Court Clerk My Commission Expires: Adm. R. 9(f)(1), Adm. R. 10; Adm. R. 12(e)(2); Civil R. 90.3 Page 3 of 3 TF-920 (10/17)(cs) REQUES T FOR EXEMPTION FROM PAYME NT OF FEE S, AND ORDER ORDER IT IS ORDERED that the request for exemption from payment of fees is: GRANTED. Plaintiff ’s/defendant ’s request for exemption from paying fees is granted. DENIED. Plaintiff’s/defendant’s request for exemption from paying fees is denied. Any fees now due in this case must be paid before any further action is taken. If payment is not made within 30 days after notice of the order, the court will dismiss the action without further notice. You may file the action again later if you pay the filing fee or receive a fee waiver. Admin. Rule 10(d). Find payment instructions at www.courts.alaska.gov/trialcourts/payments .htm, or contact your local court clerk. Date Judicial Officer I certify that on a copy of this order was sent to: Type or Print Name Clerk: