Form Mc 20 - Waiver/suspension Of Fees And Costs (Affidavit And Order)
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1
2Original - Court
3rd copy - Friend of the court
1st copy - Applicant
(when applicable)
Approved, SCAO
2nd copy - Other party
PROBATE JIS CODE: OSF
STATE OF MICHIGAN
CASE NO.
JUDICIAL DISTRICT
WAIVER/SUSPENSION OF FEES AND COSTS
JUDICIAL CIRCUIT
(AFFIDAVIT AND ORDER)
COUNTY PROBATE
Court address
Court telephone no.
Plaintiff’s/Petitioner’s name
Defendant’s/Respondent’s name
v
Plaintiff’s/Petitioner’s attorney, and bar no.
Defendant’s/Respondent’s attorney and bar no.
Probate In the matter of
Note: Requests for waiver/suspension of trancript costs or mediation fees must be made separately by motion.
AFFIDAVIT
1. I ask the court to waive/suspend fees and costs for the following reason:
(Check either a or b or c)
a. I am currently receiving public assistance: My MDHHS case number is
.
b. I receive public assistance from a source other than MDHHS. The type, source, and case number (if any) are:
c. I am unable to pay fees and costs because of indigency, based on the following facts:
My average gross income is about $
every
week.
two weeks.
month.
I am receiving unemployment benefits.
I am not employed.
I have a vehicle: Year:
Make:
Model:
Amount Owed: $
The total amount in all my bank accounts is: $
Write down any other assets and how much they are worth. If you need more space, attach a separate sheet.
I pay $
in rent/mortgage every month. I pay $
in utilities (water, electricity, gas) every
month. I pay $
for court-ordered child support. I pay $
for court-ordered
.
Specify
Write down any other obligations and how much you pay. If you need more space, attach a separate sheet.
2. The number of people living in my household is
.
3. I am signing this affidavit for a person who
is a minor.
has the following disability
.
/s/
Applicant signature
Name (type or print)
Subscribed and sworn to before me on
,
County, Michigan.
Date
My commission expires:
Signature:
Date
Deputy clerk/Register/Notary public
Notary public, State of Michigan, County of
ORDER
IT IS ORDERED:
4. The applicant has shown by ex parte affidavit that he/she is
a. receiving public assistance, and payment of fees and costs is waived/suspended pursuant to MCR 2.002(C).
b. indigent and payment of fees and costs is waived/suspended pursuant to MCR 2.002(D).
The applicant is required to notify the court if the reason for waiving/suspending the fees and costs no longer exists.
5. The application is denied.
Date
Judge
Bar no.
Note: This order must be served on the other party at the time the pleading is served.
WAIVER/SUSPENSION OF FEES AND COSTS (AFFIDAVIT AND ORDER)
MC 20 (6/17)
MCR 2.002
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