Court Fee Waiver Financial Hardship Form
Applicant Information
Full Name
Date of Birth
Address
Phone Number
Email (if any)
Case Information
Case Number
Court Name
Case Type
Financial Information
Employment Status
Employed
Unemployed
Student
Retired
Other
Monthly Income
Monthly Expenses
Number of dependents
Assets (describe)
Liabilities (loans, debts, etc.)
Reason for Fee Waiver Request
Please describe your financial hardship:
Certification
I certify that the information provided is true and correct to the best of my knowledge.
Applicant Signature
Date