Fillable FEE WAIVER REQUEST FORM

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FEE WAIVER REQUEST FORM

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The FEE WAIVER REQUEST FORM form is 2 pages long and contains:

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  • 4 check-boxes
  • 31 other fields

Country of origin: OTHERS
File type: PDF

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FEE WAIVER REQUEST FORM
PLEASE SAVE THIS DOCUMENT ON YOUR DESKTOP BEFORE FILLING IN ANY FIELDS.
Complete this form in its entirety and attach documentation verifying your monthly income (e.g.,
social security award letter, paycheck stub, etc.). Once we have received a complete form with
documentation (via email, fax, or mail), we will respond within three business days with our fee waiver
determination. (Our email address is customerservice@sagepf.com and our fax is 888-733-5047.)
1. First name: ________________________ Last name: __________________________
If married:
Spouse first name: _________________ Last name: __________________________
2. Including yourself, your spouse, and your dependents, how many people are in your household?
______
3. Total combined monthly income before taxes (including income from you, your spouse, and
your children, if applicable): __________________
4. Monthly Expenses
Housing: ___________________________________
Food: ______________________________________
Transportation: ______________________________
Cable TV/Entertainment/Movies: ________________
Smoking/Alcohol/Gambling: ____________________
Vacations: ___________________________________
Gifts: _______________________________________
Total: ______________________________________
0
5. Amount of cash you have on hand: ____________
6. Amount of money you have in savings, checking, other bank accounts, or other financial
accounts: ____________
7. Large items you or your spouse own:
Home value: ____________ Amount owed on mortgage: ____________
Motor vehicle value: ____________ Amount owed on car loan: ____________
8. Have you paid or will you pay an attorney or bankruptcy preparer to assist you in filing
bankruptcy?
____Yes
____No
If yes, how much will you pay your counsel/preparer by the end of the process?
_____________
“I certify that all statements and information furnished within and as a part of this statement are true,
complete and correct to the best of my knowledge, and are made in good faith. I understand that
statements or information furnished within or as part of this form are subject to verification and I agree
to furnish any supporting documents or information upon request. I also understand that any intentional
misstatements will be considered as sufficient cause to reject this application. If I choose to provide an
electronic signature, I agree that my electronic signature will serve as the legal equivalent of a manual
signature on this form.”
Signature: ________________________________________ Date: ________________
Name (Print): ____________________________________________________________
Spouse’s Signature (If applicable): ___________________________________________
Spouse’s Name (If applicable): ______________________________________________
Bankruptcy Case Number: ___________________
Last Four Digits of Your Social Security Number: _________ State: _______________
Email Address: ____________________________________ Phone: _______________
You would like to take the course by: ___internet ___phone
3830 Vanalden Ave., Tarzana, CA 91356 · 800-516-2759 · www.sagepf.com · customerservice@sagepf.com
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FEE WAIVER REQUEST FORM

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Completed 21 April 2022

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