Legal Fee Waiver Form

LEGAL FEE WAIVER FORM

This Legal Fee Waiver Form is entered into between Applicant Name: and Legal Service Provider Name: . Application Date: .

RECITALS

WHEREAS, the Applicant seeks representation or services from the Legal Service Provider in connection with legal matters described below and requests a waiver or reduction of fees otherwise charged for specified services; and

WHEREAS, the Legal Service Provider has an established fee waiver policy that permits, at the Provider's discretion, partial or full waivers where the Applicant demonstrates financial hardship and the waiver serves the interests of justice; and

WHEREAS, the Applicant has submitted a sworn financial disclosure and supporting documents to permit evaluation of the requested waiver.

NOW THEREFORE

In consideration of the mutual covenants contained herein and other good and valuable consideration, the sufficiency of which is acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement: "Waived Fees" means those fees listed in Section 2 below; "Applicant" means the person or entity named above; "Provider" means the Legal Service Provider named above.

2. SCOPE OF WAIVER

The Provider hereby agrees to the following as to Waived Fees (select all that apply):

Waiver of filing and administrative fees
Waiver of attorney or representation fees
Waiver of court costs and service fees
Other (describe below)

3. FINANCIAL DISCLOSURE

The Applicant certifies the following financial information under penalty of perjury. All amounts are monthly unless otherwise indicated.

4. SUPPORTING DOCUMENTATION

The Applicant has provided or will provide copies of documentation reasonably necessary to verify the information above. Typical supporting items include pay stubs, benefit statements, bank statements, or affidavits of indigency.

5. CERTIFICATION AND ACKNOWLEDGMENT

I certify under penalty of perjury under the laws of the applicable jurisdiction that the information provided in this form and in any accompanying documentation is true, complete, and correct to the best of my knowledge. I understand that knowingly submitting false information in order to obtain a fee waiver may subject me to civil or criminal penalties and to denial or revocation of the waiver.

6. EFFECT OF WAIVER

A fee waiver, if granted, applies only to those fees specified in Section 2 and for the matter expressly identified by the Provider. A waiver does not constitute an admission of liability by the Provider and does not alter other contractual obligations unless set forth in writing. Any fee amounts that are not waived remain due and payable in accordance with Provider policies.

7. CONFIDENTIALITY AND USE OF INFORMATION

Financial information provided under this form will be used solely for the purpose of evaluating and administering the fee waiver request, and will be treated as confidential to the extent permitted by law. The Provider may disclose such information to third parties when necessary to verify information or as required by law.

8. NOTICES

Notices required under this Agreement shall be given in writing and delivered to the addresses below or to such other address as the party may designate by written notice.

9. AMENDMENT; WAIVER

Any amendment to this Agreement must be in writing and signed by both parties. No provision of this Agreement may be waived except by a written instrument signed by the party granting the waiver.

10. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the jurisdiction in which the Provider maintains its principal office, without regard to its conflict of law principles.

11. ENTIRE AGREEMENT

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written agreements and understandings concerning the fee waiver request.

12. SEVERABILITY

If any provision of this Agreement is held invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect, and the parties shall negotiate in good faith to replace the invalid provision with a valid provision that comes as close as possible to the parties' intent.

OTHER PROVISIONS

The Provider may, in its sole discretion, require periodic re-certification of financial status and may modify, revoke, or terminate any waiver upon material change in circumstances or discovery of material misrepresentation.

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