Fill and Sign the Form 2dc13

                 REQUEST FOR RELIEF FROM COURT COSTS;   DECLARATION; ORDER  Form #2DC13 IN THE DISTRICT COURT OF THE SECOND CIRCUIT  DIVISION  STATE OF HAWAI‘I  Reserved for Court Use Civil No. Plaintiff Defendant Filing Party/Attorney Name, Attorney Number, Firm Name (if applicable), Address, Telephone and Fax Number or Email Check if you are an attorney representing the filing party pro bono REQUEST FOR RELIEF FROM COURT FILING FEES  Pursuant to Hawai‘i Revised Statutes §607-3, the filing party in this case asks the court to waive the prepayment of court filing fees as set forth in Hawai‘i Revised Statutes §607-4(b) because he or she is unable to pay such costs and provide for his or her necessities in life. Please answer the following questions: 1. Are you currently employed? Yes No a. If the answer is Yes, State the amount of your monthly salary/wages: $ _ Name and address of your employer: _ b. If the answer is No, State the date you were last employed:_ Name and address of your former employer: _ 2. Do you rent or own your home? State the amount of your monthly rent/mortgage payment: $__If you rent, do you receive any rent assistance? (Section 8) Yes No 3. Do you own any real estate other than your home? Yes No If the answer is Yes, state the total value: $ 4. Do you have any money in any bank account? (Include any funds in prison accounts.) Yes No If the answer is Yes, state the total amount: $__ ______________________________    � ______________________________________________________________ _______________________________________________________________ ______________________________________________________________ � � _____________________________________________________________________________________________________ ____ ________________________________________________________________________ � � _____________________________________________________________________________________________________ ____ _____________________________________________________ � � � � ____ ________ � � _______________________________________________________________________ ____________________________________________________________________ � � � � (Rev. 7/25/2017 ) Page 1 of 2 Form 2DC13 Reprographics (09/11) 2D 2D -P- 226 SEE PAGE 2 � � (continued on page 2) CommonLook ® 508 Certified REQUEST FOR RELIEF FROM COURT FILING FEES (continued)  5. Do you own any motor vehicles? Yes No 6. Do you receive any of the following (check all that apply)?: Social Security payments (e.g. SSI or SSDI) or Retirement? Supplemental Nutrition Assistance Program (SNAP) Temporary Aid to Needy Families (TANF) [formerly AFDC] Food Stamps (GA) 7. List any persons who depend upon you for financial support. State your relationship to those persons and state how much you contribute to their support. 8. Do you have any other sources of income not listed above? Yes No If the answer is Yes, describe what other income you receive. DECLARATION  I DECLARE UNDER PENALTY OF PERJURY THAT WHAT I HAVE STATED IS TRUE AND CORRECT . Date: Signature of Filing Party/Attorney: Print/Type Name: (Reserved For Court Use) ORDER  G G Having reviewed the request for relief from costs the court : This request is GRANTED court filing fees are waived. The request is  DENIED. Date: Judge In accordance with the Americans with Disabilities Act , and other applicable State and Federal laws, if you require an accommodation for your disability when working with a court program, service, or activity please contact the District Court Administration Office at PHONE NO. 244-2800, FAX 244-2849, or email adarequest@courts.hawaii.gov at least (10) working days before your preceeding, hearing, or appointment date. For Civil related matters, please call 244-2706 or visit the Service Center at 2145 Main Street, Room 141A, Wailuku, Hawai‘i 96793. CommonLook ® 508 Certified � � � � � � � � 2D-P- 226 (Rev. 7/25/2017 ) Page 2 of 2 Form #2DC13