Fill and Sign the Please Answer the Questions below Aws Form

Please answer the questions below. When you answer the questions, they will automatically fill in that information where it belongs on the following forms that you will be filing with the court. Do not leave any questions blan k. Any changes you make must be made to these questions; you will not be able to mo dify your answers in the forms themselves. Please have all of your information handy when you are answering these q uestions. 1. What is the name of the County? ________________________ 2. What is your full name? ____________________________________________________________ 3. What is your street address? ____________________________________________________________ 4. What is your town, state, and ZIP Code? ____________________________________________________________ 5. What is the full name of the other party? ____________________________________________________________ 6. What is the street address of the other party? ____________________________________________________________ 7. What is the town, state and ZIP Code of the other party? ____________________________________________________________ 8. What are the names of the family members who live with you (this is considered “household”)? _______________________________________________________________________ 9. How much do you get paid an hour? ____________ 10. How many hours do you work in a month? ____________ 11. Do you or anyone else in your household receive money from unemployment? If yes, what is the monthly amount recei ved, before any taxes are taken out? ____________ 12. Do you or anyone else in your household receive AFDC/TANF benefits? If yes, what is the monthly amount received, before any taxes are taken out? ____________ 13. Do you or anyone else in your household receive SSI/SSD benefits? If yes, what is the monthly amount received, before any taxes are taken out? ____________ 14. Do you or anyone else in your household receive money from child support? If yes, what is the monthly amount received, before any taxes are taken out? ____________ SELECT ONE 15. Do you or anyone else in your household receive any other monthly income not asked for above? If yes, what is the monthly amount received, before any taxes are taken out? ____________ 16. What is the total amount of money you have in your bank, including checking and savings accounts? ___________________ 17. How much does your household pay each month for the following expenses? a. housing? ____________ b. utilities? (gas, electricity, water, telephone, etc.) ____________ c. food? ____________ d. child care? ____________ e. medical bills? ____________ f. transportation? ____________ g. insurance? (car, medical and/or property) ____________ h. child support? (pay out, not receive) ____________ 18. Are there other expenses your household pays out each month? If yes, please describe the other expenses. _______________________________ How much is paid out each month? ____________ You have finished answering the questions. The following pages are th e forms that you will be printing and then filing with the court. Please look over them to m ake sure the information is correct before you print them out. If you have changes, you must ma ke them to the questions above. Once you have printed this packet, make sure you sign it on the Signat ure line. Your signature must be on these forms before you make copies and file it with the court. Page 1 of 1 Form PS-33373 -1 Revised by State Court Administration 10/10 STATE OF INDIANA ) IN THE SUPERIOR/CIRCUIT COURT ) SS: COUNTY OF ) CASE NO. Petitioner, V. VERIFIED MOTION FOR FEE WAIVER Respondent. The Petitioner now states: 1. I wish to file this action and I believe that I have a case with merit. 2. I cannot pay any of the filing fees or other costs of this action because I do not have sufficient income or resources. 3. I live with ___________________________________________________________________. 4. Our family’s income is ____________ per month. (Total from below) ( Income received each month, before taxes ) Wages (_______ per hour x _________ hours per month) ____________ Unemployment Compensation ____________ AFDC / TANF Benefits ____________ SSI / SSD Benefits ____________ Child Support ____________ Other + ____________ Total = ____________ 5. We have ____________ in the bank. 6. Our expenses total ____________ per month: (Total from below) (Expenses spent each month ) Housing (Rent, Contract, or Mortgage) ____________ Utilities (Gas, Electric, Water, Phone, etc.) ____________ Food ____________ Child Care ____________ Medical Bills ____________ Transportation ____________ Insurance (car, medical and/or property) ____________ Child Support ____________ Other (please describe) + ____________ _______________________________ Total = ____________ I request that this Court waive all costs of this action and allow me to proceed without the payment of any filing fees or other costs. I affirm under the penalties of perjury that the foregoing representations are true. _____________________________ Signature SELECT ONE SELECT ONE $0.00 $0.00 $0.00 $0.00 $0.00 Page 1 of 1 Form PS-33373-2 Revised by State Court Administration 10/10 STATE OF INDIANA ) IN THE SUPERIOR/CIRCUIT COURT ) SS: COUNTY OF ) CASE NO. Petitioner, V. Respondent. ORDER ON FEE WAIVER The Petitioner, has filed a Verified Motion for Fee Waiver, which the Court has read and finds should be granted. IT IS THEREFORE ORDERED that Petitioner may file this case: _____ without the pre-payment of any filing fees, costs, security, bond, or other expenses; or _____ upon the pre-payment of $_____________ which is a portion of the filing fee set by statute. Such sum must be paid by the Petitioner to the Clerk within the next 20 days. The Court will determine whether any or additional costs are to be paid at a preliminary or final hearing in this case. _________________________ __________________________________ Date Judge Distribution: SELECT ONE SELECT ONE