Waiver/suspension Of Fees And Costs (Affidavit And Order) Form Mc-20
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1
2Approved,
SCAO
Original - Court
1st copy
-
Applicant
2nd copy
-
Friend of the
court
(when
applicable)
PROBATE
JIS
CODE: OSF
STATEOFMICHIGAN
o.rlr
JUD|C|ALOISTRICT
orrr
JUDrcrALcrRcurr
COUNTYPROBATE
CASENO.
Court
telephone
no.
(616)
s27
-5310
Gourt
address
1IO E
WASHINGTON STREET*IONIA
MI
48846
WAIVER/SUSPENSION
OF FEES
AND COSTS
(AFFTDAVTTANDORDER)
Pla
intiff/Petitioner name
v
DefendanURespondent name
Plaintiffs/Petitioner's attorney and bar
no.
Defendant's/Respondent's attorney and bar
no.
I
Probate
ln the
matterof
NOTE:
Requests
for waiver/suspension of transcript costs or mediation fees must be made separately by
motion.
1,
I
ask the court
to
waive/suspend fees and costs for the following reason:
(check either
a
or
b)
I
a.
I
am currently receiving public
assistance: My DHS
c€lse
number
is
(MCR 2.002[C] requires the court
to
suspend payment
of
fees
and
costs")
OR
I
O.
t
am unable to
pay
fees and costs because
of
indigency, based
on the
following facts:
My
average gross income
is
about
$
every
[
week.
[l
t
am
receiving unemptoyment benefits
I
lam notemployed.
E
lhaveavehicle:Year:
Make:
Model:
f]
trvo
weeks.
Amount
Owed:
$
fl
month
The total amount
in
all my bank accounts
is:
$
Write down any other assets and how much they are
worth.
lf
you need more space, attach a separate
sheet
lpay$
in
renVmortgage every
month.
I
pay $
in utilities (water, electricity, gas) every
month'lpay$-forcourt.orderedchildSupport.lpay$-forcourt-ordered-.
write
down any other obligations and how much you
pay.
lf you need
more
space, attach a separate
sheet-
specify
2.
The
numberof people living
in my
household
is
I
g.
I
am
signing this affidavit
for
a
person who
fl
is
a minor
I
has the
following disability
Applrcant
srgnature
Name
(type
or
print)
Subscribed
and
sworn
to
before
me on
County, Michigan.
My commission
expires:-
Signature:
Deputy clerURegister/Notary
public
Notary public, State
of
Michigan, County
of
ITISORDERED:
[l
t.
fne
applicant
has
shown
by
ex
parte
affidavit that he/she
is
I
a" receiving
public
assistance,
and
payment
of
fees
and
costs
are
waivedlsuspended pursuant
to MCR
2.002(C).
[lU.
inOigentandpaymentoffeesandcostsarewaived/suspendedpursuanttoMCR2.0O2(D).
The applicant
is
required to notify
the
court
if
the reason
for
waiving/suspending
the
fees and costs
no
longer exists.
[l
Z.
the
application
is
denied.
Date
Judge
Mc20
(8t12)
wAlvER/susPENSloN oF
FEES
AND COSTS (AFFIDAVIT AND ORDER)
MCR2.002
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