Fillable APPLICATION FOR FEE WAIVER AND STATEMENT OF FINANCES (Alberta Student Aid)

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APPLICATION FOR FEE WAIVER AND STATEMENT OF FINANCES (Alberta Student Aid)

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The APPLICATION FOR FEE WAIVER AND STATEMENT OF FINANCES (Alberta Student Aid) form is 3 pages long and contains:

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  • 25 check-boxes
  • 51 other fields

Country of origin: CANADA
File type: PDF

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APPLICATION FOR FEE WAIVER
AND STATEMENT OF FINANCES
Resolution and Court Administration Services
https://www.alberta.ca/waive-filing-fee.aspx March 2020
Page 1 of 4
COURT FILE NUMBER
COURT Court of Appeal of Alberta
Court of Queen’s Bench of Alberta
Provincial Court of Alberta
LOCATION /
JUDICIAL CENTRE
APPLICANT
DOCUMENT Application for Fee Waiver
and Statement of Finances
CONTACT INFORMATION OF
PARTY FILING THIS DOCUMENT
Name:
Address:
Phone:
(Home)
(Work)
File No.:
For Court use only:
Senior Judicial Clerk Review:
(signature)
(printed name)
Application for Fee Waiver:
Granted and valid until:
_______________________________________________________, (date
– which is six months from date of granting)
or
Denied: ___________________________________________
(reasons)
_______________________________________________________
Supervisor/Manager Review
(if requested):
(signature)
(printed name)
I confirm that the senior judicial clerk’s findings as set out above are
correct,
or
Application for Fee Waiver granted, and valid until:
_______________________________________________________
(date – which is six months from date of granting)
_______________________________________________________
(reasons for change)
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APPLICATION FOR FEE WAIVER
AND STATEMENT OF FINANCES
Resolution and Court Administration Services
https://www.alberta.ca/waive-filing-fee.aspx March 2020
Page 2 of 4
The following information is needed to determine whether you are eligible for a waiver of certain fees payable to court officials.
Please note that this Statement of Finances must be completed in full and proof of income provided.
Failure to provide complete or accurate information will result in your request for waiver of filing fees being rejected.
I, , declare that:
1. I am not representing a business or an estate in the action or proceeding.
2. There are no other parties joined with me in the action or proceeding who are able to pay the
applicable court fees.
3. I am (check applicable box):
married living in an adult interdependent relationship
single living common law
4. The number of people in my household, including me, my spouse or adult interdependent
(common law) partner, dependent children, and any other family members is: (specify the number
of persons living in the same dwelling and related by blood, marriage, common-law or adult
interdependent relationship, or adoption. Note: The number of persons residing in the household includes
you. A child residing with you for at least 50% of the time is counted as a member of your household.)
1 2 3 4 5 6 7+
5. Listed below is an accurate statement of finances for my household, which includes all income
received in my household during approximately the past three months, from
to .
Gross Income from All Sources for Three Month Period
(Before income taxes, and other mandatory deductions)
Description
Amount
Employment
$
Employment Insurance
$
Workers Compensation / Disability Pension
$
Social Assistance (Support for independence)
$
Maintenance
$
Income from children (if any)
$
Rental Income
$
Investment Income
$
Other (specify):
$
$
Gross income of spouse / common law partner /
adult interdependent partner living with me
$
TOTAL GROSS INCOME for Three Month Period
$
Average Gross Monthly Family Income
$
APPLICATION FOR FEE WAIVER
AND STATEMENT OF FINANCES
Resolution and Court Administration Services
https://www.alberta.ca/waive-filing-fee.aspx March 2020
Page 3 of 4
6. Below is additional financial information I believe is relevant:
I solemnly declare that the above information is correct. I make this solemn declaration conscientiously believing it
to be true and knowing it is of the same force and effect as if made under oath.
WARNING: A false declaration constitutes a criminal offence and is punishable by law.
Signature of Declarant
Declared before me at , Alberta,
this day of , 20 .
Commissioner for Oaths in and for the
Province of Alberta
You must bring proof of your household income, including the following items:
1. Proof of your income, including either:
A copy of your income tax return or notice of assessment/reassessment for the most recent
taxation year, or pay stubs or income statements for the last 3 months from all of your sources of
income; OR
If you are not employed, proof of the source and amount of your income for the last 3 months; OR
If you currently receive government financial assistance, proof of current receipt of benefits such as:
Employment Insurance (EI) from the Government of Canada; or
Canada Pension Plan Disability Benefit, or Guaranteed Income Supplement (GIS) from the
Government of Canada; or
Income Support Benefits, Alberta Works, or Assured Income for the Severely Handicapped
from the Government of Alberta, or your current Alberta Health Benefits Card.
2. Copies of your spouse’s / common law partner’s / adult interdependent partner’s pay stubs or income
statements for the last 3 months from all of their sources of income;
3. Any other documents necessary to establish your financial situation.
Note: Please advise the clerk if you are unable to produce the applicable documents.
The Court Clerk or Registrar (or their designate) will review your request and determine if your gross family
income is below the income threshold set out in the Ministerial Order establishing the guidelines for an applicant
to be granted a waiver of certain fees payable to court officials
The personal information collected on this form will be used for the purpose of determining if you qualify for a waiver of court filing fees. This
collection of personal information is in compliance with section 33(c) of the Freedom of Information and Protection of Privacy Act. If you have
any questions about the collection of personal information please contact the Executive Director, Organizational Strategy and Transformation
at 780 427 4992 or write to: Executive Director, Organizational Strategy and Transformation, Resolution and Court Administration, Alberta
Justice and Solicitor General, 9th Floor J.E Brownlee Building, 10365 – 97th Street, Edmonton, AB, T5J5A6.
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APPLICATION FOR FEE WAIVER
AND STATEMENT OF FINANCES
Resolution and Court Administration Services
https://www.alberta.ca/waive-filing-fee.aspx March 2020
Page 4 of 4
Income Thresholds
Number of Persons in Family Residing in
Household (including applicant)
Gross Family Income
$ Monthly
$ Annually
1
2230
26,760
2
2776
33,315
3
3413
40,957
4
4144
49,727
5
4700
56,400
6
5301
63,609
7+
5902
70,819
The term “Gross Family Income” means all monies received by the family before income taxes or
deductions.
“Family” includes all persons living in the same dwelling and related by blood, marriage, common-law or
adult interdependent relationship, or adoption. In the case of common-law and adult interdependent
relationships, common law spouses, adult interdependent partners and their dependents are
considered family. In the case of a minor, unless the young person lives independently, it is the income
of the minor’s parents or guardians which determines eligibility.
Review Process
A Senior Judicial Clerk can only grant a fee waiver if the applicant qualifies to apply for a fee waiver and
their Gross Family Income falls within the Income Threshold set out above. If the applicant disagrees
with the Senior Judicial Clerk’s findings, the applicant may ask that the findings be reviewed by a
Supervisor/Manager. However, the Supervisor/Manager is governed by the same guidelines as the
Senior Judicial Clerk.
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APPLICATION FOR FEE WAIVER AND STATEMENT OF FINANCES (Alberta Student Aid)

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Completed 27 June 2022

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