Fillable Form 106A - SCB: SUPERIOR COURT OF THE (Superior Court of DC)

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Form 106A - SCB: SUPERIOR COURT OF THE (Superior Court of DC)

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Form 106A - SCB
SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
SMALL CLAIMS AND CONCILIATION BRANCH
Plaintiff/Petitioner
v. Case no:
Defendant/Respondent
APPLICATION TO PROCEED WITHOUT PREPAYMENT
OF COSTS, FEES, OR SECURITY
Form 106A - SCB
I, am the (check one)
Plaintiff/Petitioner Defendant/Respondent
I need an interpreter for this case. I speak the following language:
[Insert Language].
I respectfully ask permission to proceed in this case without pre-paying costs
or fees and without giving security for them because I am not able to do so
without substantial hardship to myself or to my family. In support of this
request, I state the following:
Check and answer only those that apply.
INCOME
1. I receive the following public benefits, and the law presumes that I
am eligible to proceed without prepayment of costs, fees, or security
(see D.C. Code § 15-712):
Temporary Assistance for Needy Families (TANF)
General Assistance for Children (GAC)
Program on Work, Employment and Responsibility (POWER)
Supplemental Security Income (SSI)
2. Even though I do not receive the above public benefits, I receive the
following similar benefits and, therefore, request that my Application be
approved:
Interim Disability Assistance (IDA) because my SSI application
has not been approved/certified
Medicaid
DC Healthcare Alliance or the following similar health benefits
(describe)
.
If you checked any of the above boxes, you do not need to answer any
more questions and may skip to the section called “Declaration.”
Otherwise, you must answer the rest of the questions on this form. If
additional information is required, you will be notified.
3. My total income over the past 12 months from all sources
(including, but not limited to, my job, other wages or business
income, rental income, pensions, annuities or life insurance
payments, worker’s compensation, unemployment compensation or
insurance, annual interest or dividends, gifts, alimony or spousal
support, inheritance or trust income) is $ .
4. I am presently unemployed. The last date I worked was on
,
.
Month
Year
DEPENDENTS
5. How many people live in your household and depend on you for
support:
.
Of these people, how many are minor children or
elderly? .
2 Form 106A-SCB
ASSETS
6. I state the following about my property:
I have $
accounts.
in cash, including money in savings or checking
I own the vehicles, personal home, other real estate, stock, bonds, or
other valuable property, besides household furnishings and clothing,
listed below:
.
List the Property
EXPENSES
7. This is my best estimate of the monthly expenses for myself and the
people in my household who depend on me for support:
Housing (rent, mortgage, taxes, & insurance): $
Public Transportation and Gasoline: $
Automobile
Loan, Insurance, Maintenance: $
Health (medical, dental, vision, prescriptions, insurance): $
Food and other Household Necessities: $
Utilities (including gas, electric, water, phone, internet): $
Clothing: $
Child Support: $
Childcare (including diapers, daycare): $
Other (explain in detail): $
Total Estimated Monthly Expenses: $
3 Form 106A-SCB
OTHER SPECIAL CIRCUMSTANCES
8. (Optional) Explain any other special circumstances that you
want to have considered in support of your request, including any
large monthly expenses, debts, wage or bank account
garnishments, and/or judgments.
.
4 Form 106A-SCB
DECLARATION
REQUIRED: I solemnly swear or affirm under criminal penalties for the
making of a false statement, which includes 180 days in jail or a $1,000 fine
or both, that I have read this Application and that the factual statements
made in it are true to the best of my personal knowledge, information and
belief.
1
Signature
Address
Phone Number
Date
POINTS AND AUTHORITIES IN SUPPORT OF APPLICATION TO
PROCEED WITHOUT PREPAYMENT OF COSTS, FEES, OR SECURITY
1. D.C. Code § 15-712.
2. D.C. Code § 22-2405.
3. Civil Rule 54-II, Domestic Relations Proceedings Rule 54-II, and Family
Rule R.
4. Adkins v. E.I. Du Pont de Nemours & Co., Inc., 335 U.S. 331 (1948).
5. Harris v. Harris, 137 U.S. App. D.C. 318, 322, 424 F.2d 806 (1970),
cert. denied, 400 U.S. 826 (1970) (“in forma pauperis relief not limited
to those who are public charges or absolutely destitute”).
6. Green v. Green, 562 A.2d 1214 (D.C. 1989) (statute “effectuates the
fundamental principle that every litigant should be provided equal access
to the courts without regard to financial ability”).
7. Herbin v. Hoeffel, 727 A.2d 883, 887 (D.C. 1999) (court officers serve
process in in forma pauperis cases).
8. Cabillo v. Cabillo, 317 A.2d 866, 866 (D.C. 1974) (per curiam)
(reversing denial of in forma pauperis status and mandating granting of
petition where litigant’s income “only slightly above the welfare
standard”).
___________ _______ __________ __________ __________ __________ _______ __________ __________ __________ __________ __________ _______ __________ __________ __________ __________ _______ __________ __________ _________ __________ __________ ______ __________ __________ ___________ __________ ______ __________ __________ __________ ___________ __________ ______ ________
1
When you come to court, you may be asked questions about this Application. If your
responses are not truthful, you could face additional criminal penalties.
5 Form 106A-SCB
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signature
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SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
FAMILY COURT and CIVIL DIVISION
Plaintiff/Petitioner
v. Case No.
Defendant/Respondent
ORDER
Having considered Plaintiff/Petitioner’s Defendant/Respondent’s
Application to Proceed without Prepayment of Costs, Fees, or Security, it is
hereby ordered that the Application is:
GRANTED in this Family Court case and, pursuant to Domestic
Relations Rule 54-II, witnesses will be subpoenaed without
prepayment of witness fees;
GRANTED in this Civil Division case and, pursuant to Civil Rule 54-II,
the officers of the Court will issue and serve all process; witnesses will
be subpoenaed without prepayment of witness fees;
DENIED
For the following reasons:
For the reasons stated on the record in open court and in the
presence of the applicant or his or her counsel;
Date Judge
6 Form 106A-SCB
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Completed 15 July 2021

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