Form Jdf 205 - Request To Waive Mediation Fee
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1
2District Court
LARIMER County, Colorado
Return APPROVED form to:
Your assigned mediator
Larimer County
Plaintiff/Petitioner:________________________________________
v.
COURT USE ONLY
Case Number:
Defendant/Respondent: __________________________________
Courtroom:
REQUEST TO
:
WAIVE MEDIATION FEE
I, _____________________________________ respectfully request waiver of the followting fees
other: Mediation fees and/or
to appoint and pay for an interpreter pursuant to CJD 06-03 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
Other Responsible Party
(Spouse, Parent, Other Persons in Household)
Last Name
First Name
MI
Last Name
First Name
MI
Street Address
Street Address (
(Include Apt. # if applicable)
Include Apt. # if applicable)
____________________________________________________
____________________________________________________
______________________
____________
______________________
____________
City
State
Zip Code
City
State
Zip Code
Own
Rent Home Phone #: _____________________
Own
Rent Home Phone #: ____________________
Social Security #
Driver's Lic. # & State
Date of Birth
Social Security #
Driver's Lic. # & State
Date of Birth
Most Recent Employer: ______________________________
Most Recent Employer: ______________________________
Work Address: _____________________________________
Work Address: _____________________________________
Work Phone #: (
) _______________________________
Work Phone #: (
) _______________________________
Dates Employed: ___________________________________
Dates Employed: ___________________________________
Hours/Week: ___________ Pay Rate: $ ________________
Hours/Week: ____________ Pay Rate: $ ________________
Pay Dates:
Pay Dates:
Marital Status:
Number in Household:
Single
Married
Divorced
Separated
Widowed
____
(including yourself)
Identify Name, Age, and Relationship:
Gross Monthly Income (See Information on page 2)
Monthly Expenses (See Information on Page 2)
Self (wages, salary, commission)
$
Rent or Mortgage
$
Spouse/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
$
$
If incarcerated, amount in Inmate Account $ ________________. (Attach copy of Inmate Trust Fund Account statement for a
six-month period immediately preceding filing pursuant to §13-17.5-103, C.R.S.)
Cash on Hand (Cash you are carrying or
$
(Show type and balance owed)
Credit Cards:
which is stored at home, etc.)
Checking Account Balance
$
Name/Address of Bank
Savings Account Balance
$
Name/Address of Bank:
Stocks, Bonds, or other Investments
$
Type of Investment, Name/Location of Company/Corporation
Held Balance
Vehicles Owned (Autos, boats,
$
Identify Year _______Model ____________License Plate__________
Identify Year _______Model ____________License Plate__________
recreational vehicles, etc.) -
Estimate Value
House(s) or other Property -
$
Amount owed, Year Purchased
Estimate Value
IF ADDITIONAL SPACE IS NEEDED TO PROVIDE COMPLETE INFORMATION, ATTACH A SEPARATE
PAGE.
I swear under penalty of perjury that all information provided is true and complete. In addition, I authorize the Court to
make any necessary contacts to verify the information.
Signature: ___________________________________ Date: ___________________
JDF 205
R11/06
MOTION TO: FILE WITHOUT PAYMENT OF FILING FEE/APPOINT AND PAY INTERPRETER AND SUPPORTING FINANCIAL AFFIDAVIT
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