Fill and Sign the Petition and Waiver of Feescosts Affidavit of Indigency and Form

CV-410, 06/00 Petition for W aiver of Filing and Service Fees - Affidavit of Indigency and Order §814.29, W isconsin Statutes. This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY -vs- Petition for Waiver of Filing and Service Fees - Affidavit of Indigency and Order Case No. For Official Use Under oath I state that because of poverty, I am unable to pay the filing and service fees of this action, proceeding, or appeal, or to give security for those fees, and request waiver of those fees. I am attaching and incorporating into this affidavit a copy of my pleading in this matter. Complete Section 1 if you receive aid from any of the programs listed. Section 1. If you do not receive aid, complete Section 2 on page 2. I currently receive: Supplemental security income Relief funded under §59.53(21), Wis. Stats. Medical assistance Food stamps Relief funded under public assistance Benefits for veterans under §45.351(1) or 38 USC 501-562 Legal representation from a civil legal services program or a volunteer attorney program based on indigency. Name of program: Other means-tested public assistance: My financial situation has has not changed since I became eligible for this program. If you checked the “has” box, and such changes would make you ineligible for the program(s) if you applied today, you must complete Section 2 on page 2 of this form. Subscribed and sworn to before me on Notary Public/Court Official My commission expires: I understand that if my financial situation changes, I must notify the court immediately. Signature Date Address COURT FINDINGS AND ORDER 1. This petition is GRANTED because the court finds the person is indigent. The action may be commenced without payment of filing fees . The sheriff shall serve all necessary documents without payment of service fees. If these fees are recovered, the amount shall be used to pay the filing and service fees waived by this order. Any request for waiver of any other fees or costs must be made to the court for consideration and decision. 2. This petition is DENIED because the court finds the petitioner not indigent but unable to pay the filing or service fees at this time. This action may be filed by the Clerk and all necessary documents may be served by the sheriff without prepayment of fees. Such fees must be paid no later than . 3. This petition is DENIED because the court finds: the petitioner is not indigent. allegation of poverty to be untrue. the petitioner has not stated a meritorious claim, defense, or appeal upon which the court may grant relief: (Brief explanation) BY THE COURT: Circuit Court Judge Original: Clerk of Circuit Court Date CV-410, 06/00 Petition for W aiver of Filing and Service Fees - Affidavit of Indigency and Order §814.29, W isconsin Statutes. This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 Petition for Waiver of Filing and Service Fees - Affidavit of Indigency and OrderPage 2 of 2 Case No. Section 2. Complete this section only if you do not qualify under Section 1, or if the instructions for that section require you to complete it. 1. I am am not married. 2. I am am not employed. Name of employer: 3. I earn $ gross weekly. every 2 weeks. twice monthly. monthly. My take-home pay is $ per payperiod. 4. I receive monthly income totaling the amount of $ from: Pension Social security Unemployment compensation Disability Student loans/grants Other: 5. I have the following cash assets: Savings accounts: $ Cash: $ Checking accounts: $ Money owed me: $ 6. I have the following other assets: Vehicle-Yr./Make: $ Household furnishings: $ Vehicle-Yr./Make: $ Equity in real estate: $ Other individual assets valued over $200 each: $ 7. My household consists of myself and others: Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No 8. The other members of my household have monthly income totaling the amount of $ from: Wages Social security Relief funded under public assistance Food stamps Pension Student loans/grants Unemployment compensation Supplemental security income Disability Relief funded under §59.53(21), Wisconsin Statutes Support/maintenance Other: 9. I have the following debts; Amount: Monthly Payment: a. Mortgage $ b. Auto loan $ c. Credit cards $ d. Other: $ $ 10. I have the following unusual expenses, other than ordinary living expenses: