Affidavit And Order For Suspension Of Filing Fees Form - Michigan 10th Judicial Circuit Page 2
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1
2STATE OF MICHIGAN
AFFIDAVIT AND ORDER FOR
CASE NO.
th
10
JUDICIAL CIRCUIT
SUSPENSION OF FILING FEES
FAMILY DIVISION
Court address: 111 S. Michigan Ave, Saginaw, MI 48602
Plaintiff’s Name & Address
Defendant’s Name & Address
V
V
AFFIDAVIT
1. A petition to modify________________ is to be filed with the court by__________________________________________
Applicant, who is
Plaintiff
Defendant.
Name
2. The applicant is entitled to and asks the court for suspensions of filing fees in the action for the following reason:
a. S/he is currently receiving public assistance: $__________per__________ Case No:___________________________
b. S/he is unable to pay those filing fees because of indigency, based on the following facts:
INCOME:__________________________________________________________________________________________
Employer name and address
_______________
____________
_____________
per
week
month
two weeks.
Length of Employment
Average Gross Pay
Average net pay
ASSETS: State Value of car, home, bank deposit, bonds, stocks, etc.
Obligations: Itemized monthly rent, installment payments, mortgage payments, child support, etc.
_____________________________
Affiant Signature
Subscribed and sworn before me on___________________, Saginaw, County, Michigan.
My commission expires:___________ Signature:________________________________
Date
Deputy Clerk/Register/Notary Public
ORDER
IT IS ORDERED:
1.
Filing fees in this action required by law or court rule are waived/suspended until further order of the court.
Before any final disposition or discontinuance is entered, the moving party shall bring the fee suspension to the attention
of the judge for final disposition.
2.
Whenever the reason for the waiver/suspension no longer exists, the applicant may be ordered to pay the filing fees.
3.
The application is denied.
____________________________________
___________________________________
Date
Judge
Bar No.
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