Fill and Sign the Rule Change 200115 Colorado Judicial Branch Form

Page 1 of 3 JDF 205 R10/15 MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FINANCIAL AFFIDAVIT ©2013, 2014 Colorado Judicial Department for use in the Courts of Colorado Supreme Court  Court of Appeals  Denver Juvenile Court Denver Probate Court County Court District Court ____________________ County, ColoradoCourt Address:Plaintiff/Petitioner:________________________________________v.Defendant/Respondent: ____________________________________________________________________________________________________Attorney or Party Without Attorney: (Name & Address)Phone Number: Atty. Reg. #: COURT USE ONL Y_______________________________Case Number: Courtroom: MOTION TO: FILE WITHOUT PAYMENT OF FILING FEE  WAIVE OTHER COSTS OWED TO THE STATE AND SUPPORTING FINANCIAL AFFIDAVIT I, _____________________________________ respectfully move the Court for an order to waive the following filing fee(s): complaint petition answer response motion to modify other: __________________ and as grounds state that I am without funds, have no adequate funds available, and have a meritorious claim. All items must be fully completed. Print or type neatly. If an item does not apply, please write “N/A” Name of Applicant Last NameFirst NameMIStreet Address (Include Apt. # if applicable)__________________________________________________________________________________________________________________________________________________________________________________ ________________ ____________ City State Zip CodeOwn Rent Home Phone #: _____________________Social Security #Driver's Lic. # & StateDate of BirthMost Recent Employer: ____________________________________________________________________________Work Address: ___________________________________________________________________________________Work Phone #: ( ) _______________________________Dates Employed: ___________________________________Hours/Week: _______Pay Rate: $ _____________ Weekly Bi-weekly Monthly Annual Other:_____________ Name of Other Responsible Party(Spouse, Partner, Parent, Other Persons in Household) Last NameFirst NameMIStreet Address (Include Apt. # if applicable)__________________________________________________________________________________________________________________________________________________________________________________ ___________________ ____________ City State Zip CodeOwn Rent Home Phone #: ____________________Social Security #Driver's Lic. # & StateDate of BirthMost Recent Employer: ____________________________________________________________________________Work Address: ___________________________________________________________________________________Work Phone #: ( ) _______________________________Dates Employed: ___________________________________ Page 2 of 3 JDF 205 R10/15 MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FINANCIAL AFFIDAVIT ©2013, 2014 Colorado Judicial Department for use in the Courts of Colorado IF ADDITIONAL SPACE IS NEEDED TO PROVIDE COMPLETE INFORMATION, ATTACH A SEPARATE PAGE.Gross Monthly Income (See Information on page 3)Monthly Expenses (See Information on Page 3) Self (wages, salary, commission)$Rent or Mortgage$Spouse/Partner, Other Household Members$Groceries$Parents (if same household)$Utilities$Unemployment Benefits$Clothing$Social Security/Retirement Funds$Maintenance/Alimony and/or Child Support$Maintenance/Alimony$Medical/Dental$Other Income (identify)$Other Expenses (identify)$Other Income (identify)$Other Expenses (identify)$ Total Income $Total Expenses $Cash on Hand (Cash you are carrying or which is stored at home, etc.)$Credit Cards: (Show type and balance owed)Type:______________________ Balance $____________Type:______________________ Balance $____________Checking Account Balance$Name/Address of Bank: Savings Account Balance $ Name/Address of Bank:Stocks, Bonds, or other Investments Held Balance $ _______________ ________________________________Type of Investment Name/Location of Company/Corporation ________________ ________________________________Vehicles Owned (Autos, boats, recreational vehicles, etc.) - Estimate Value $ Year _______Model ____________License Plate__________Year _______Model ____________License Plate__________House(s) or other Property Estimate Value $ Amount owed $ ____________Year Purchased__________I swear under penalty of perjury that all information provided is true and complete. In addition, if requested I will provide three (3) months of bank statements and pay stubs or other comparable proof of income status. I authorize the Court to make any necessary contacts to verify the information. Signature:______________________________________________ Date:________________Hours/Week: _________Pay Rate: $ ______________Weekly Bi-weekly Monthly Annual Other:_____________Marital Status: Single Married Partner in a Civil UnionDivorced/Civil Union Dissolved Separated Widowed Number in Household: (including yourself) ________Identify Members:_______________________________________________ __________ ______________________________ Name Age Relationship _______________________________________________ __________ ______________________________ Name Age Relationship Page 3 of 3 JDF 205 R10/15 MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FINANCIAL AFFIDAVIT ©2013, 2014 Colorado Judicial Department for use in the Courts of Colorado MOTION TO FILE WITHOUT PAYMENT SUPPORTING FINANCIAL AFFIDAVIT, AND SUPPORTING DOCUMENTATION REQUESTED General Information It is important that you accurately complete all sections of this form as appropriate based on your personal circumstances. If a section does not apply, please write N/A. A. Gross Monthly Income. Includes income from all members of the household who contribute monetarily to the common support of the household. Income categories to include:Wages, including tips, salaries, commissions, payments received as an independent contractor for labor or services, bonuses, dividends, severance pay, pensions, retirement benefits, royalties, interest/investment earnings, trust income, annuities, capital gains, unemployment benefits, Social Security Disability (SSD), Social Security Supplemental Income (SSI), Workman’s Compensation Benefits, and alimony.Note: Income from roommates should not be considered if such income is not commingled in accounts or otherwise combined with the applicant’s income in a fashion which would allow the applicant proprietary rights to the roommate’s income.Income categories do not include:TANF payments, food stamps, subsidized housing assistance, veteran’s benefits earned from a disability, child support payments, or other public assistance programs. B.Liquid Assets. Includes cash on hand or in accounts, stocks bonds, certificates of deposit, equity, and personal property or investments which could readily be converted into cash without jeopardizing the applicant’s ability to maintain home and employment. Expenses. Nonessential items such as cable television, club memberships, entertainment, dining out, alcohol, cigarettes, etc., shall not be included. Allowable expense categories are listed on JDF 205. If you are applying to have your filing fee waived you may be asked to supply:  Copies of the previous three months bank statements, including checking and savings. DO NOT provide originals. Copies of the previous three months pay stubs and/or proof of income must be included. DO NOT provide originals.