Form 228 - Application To Waive Filing Fees And Service Costs Page 2
Download a blank fillable Form 228 - Application To Waive Filing Fees And Service Costs in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 228 - Application To Waive Filing Fees And Service Costs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2APPLICATION TO WAIVE FILING FEES AND SERVICE COSTS
Other Employed Household Members
Name of Household Member
Name of Employer
Employer’s Address
Change in Monthly Income:
If your current monthly income is significantly different from last year’s income,
please describe the reasons for the change.
My income last year (past 12 months) was
$
The income from other household members last year was:
$
(This section must be filled out if you have a change in income.)
The reason for the change is:
I request the Court waive filing fees and/or pay service fees in this case because of my low income. I further state that all
of my answers are true to the best of my knowledge and belief, UNDER PENALTY OF PERJURY.
Signed and sworn before me:
Notary Public
Date
Applicant Signature
Date
DETERMINATION OF FINANCIAL ELIGIBILITY
The Application is DENIED
The gross income of the applicant and cohabitating family members is greater than 150% of
the poverty line, AND welfare aid does not constitute a major portion of subsistence of the
applicant and cohabitating family members, AND the applicant is able to pay the filing fee and
costs of service without expending income or liquid resources necessary for the maintenance
of the applicant and all dependents.
You must pay $
to the court clerk within 30 days or the case will be dismissed.
The Application is GRANTED
Welfare aid constitutes a major portion of subsistence of the applicant and cohabitating family members.
OR
The gross income of the applicant and cohabitating family members is at or below 150% of the poverty
income guidelines. OR
Applicant is unable to pay the entire filing fee and costs of service without expending income or liquid
resources necessary for the maintenance of the applicant and all dependents.
THE FILING FEES AND COSTS OF SERVICE ARE WAIVED.
The Application is GRANTED in part and DENIED in part
Applicant is a financially needy person; however, based on the financial statement, Applicant has the ability to
pay the costs of service without expending income or liquid resources necessary for the maintenance of the
applicant and all dependents.
THE FILING FEES ARE WAIVED. THE COSTS OF SERVICE ARE NOT WAIVED.
$
You must pay
In service fees to
the clerk
sheriff.
You must pay $
to the court clerk within 30 days or the case will be dismissed.
Signature of Clerk or Designee
Date
NOTICE OF RIGHT TO APPEAL: You have the right to appeal this order to the Judge of this
Court. Your appeal must be filed in writing with the clerk of this court within 7 days of the date
of this order.
Clear Form
Form 228 - IFP (11/2014)
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal