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IN RE THE MATTER OF: ) Petitioner, ) (Indiana Legal Help)

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Page 1 of 2 Approved by the Coalition for Court Access Best Practices
Group CCA-MC-0519-3018
STATE OF INDIANA ) IN TH
E __________________ _________________ COURT
)SS:
COUNTY OF ________________) CAUSE NO. ____________________________________
IN RE THE MATTER OF: )
)
)
__________________________ )
Petitioner, )
)
v. )
)
_________________ County )
Prosecutor and The Commissioner )
for the Indiana Bureau of Motor )
Vehicles, )
Respondent. )
APPEARANCE BY UNREPRESENTED PERSON IN CIVIL CASE
This Appearance Form must be filed on behalf of every party in a civil case.
1. My name is _________________________________ and I am filing this case on my own
behalf. I am not represented by a lawyer.
2. Contact information for receiving legal service of document and case information as required
by Court Rules.
Address:
Email address:
☐ I will accept service at the above email address.
Phone:
Fax:
3. This is an MC case type as defined in Administrative Rule 8(B)(3).
4. There are related
cases: (If yes, please indicate below)
☐ Yes
☐ No
Petitioner Date of Birth __________________________
Petitioner Operator License _______________________
CLEAR FORMS
PRINT FORMS
_____
Page 2 of 2 Approved by the Coalition for Court Access Best Practices
Group CCA-MC-0519-3018
Caption and case number of related cases:
Caption: Case No.:
Caption: Case No.:
Caption: Case No.:
Caption: Case No.:
Caption: Case No.:
Caption: Case No.:
Additional information as required by local rule:
Signature
CERTIFICATE OF SERVICE
I hereby certify that I sent a copy of the document to:
The Commissioner for the Indiana Bureau of Motor Vehicles by
☐ electronic transmission or
☐ US Mail at:
Indiana Government Center North
Room 402
100 North Senate Avenue
Indianapolis, IN 46204
AND
the _______________ County Prosecutor by
☐ US Mail or
☐ hand delivery or
☐ electronic transmission
on ____________________________________.
____________________________ _________________________________
Date Signature
_________________________________
Printed Name
STATE OF INDIANA ) IN THE COURT
)SS:
COUNTY OF ) CAUSE NO.________________________________
__________________________ Petitioner Date of Birth __________________________
Petitioner, Petitioner Operator License _______________________
v.
_________________ County Prosecutor
and the Commissioner for the Indiana
Bureau of Motor Vehicles,
Respondent.
VERIFIED PETITION TO WAIVE RE-INSTATEMENT FEES
Comes now the Petitioner, and for their Verified Petition to Waive Re-Instatement Fees now
states as follows:
1. I am indigent (See attached Affidavit of Indigency)
2. I reside in ________________ County, Indiana at the following address:
__________________________________________________________________________.
3. I owe fees to the Indiana Bureau of Motor Vehicles in the sum of $_______________
for reinstatement of my driver’s license. (See attached BMV Notice).
4. I will bring proof of future financial responsibility (i.e. proof of insurance) to the court
hearing.
5. My birthdate is ______________________.
6. The last four (4) digits of my driver’s license number are ______________.
7. I seek waiver of these reinstatement fees for the following reasons:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________
I hereby affirm under penalties for perjury that the foregoing statements are true and correct.
______________________________ ______________________________________
Date Signature
Page 1 of 2
Approved by the Coalition for Court Access
CCA-MC-0619-2032
_____
Page 2 of 2 Approved by the Coalition for Court
Access CCA-MC-0619-2032
CERTIFICATE OF SERVICE
I hereby certify that I sent a copy of the document to:
The Commissioner for the Indiana Bureau of Motor Vehicles by
☐ electronic transmission or
☐ US Mail at:
Indiana Government Center North
Room 402
100 North Senate Avenue
Indianapolis, IN 46204
AND
the _______________ County Prosecutor by
☐ US Mail or
☐ hand delivery or
☐ electronic transmission
on ____________________________________.
____________________________ _________________________________
Date Signature
__________________________________
Printed Name
Page 1 of 1 Approved by the Coalition for Court Access
CCA-MC-0819-2034
STATE OF INDIANA IN THE COURT
COUNTY OF CAUSE NO.______________________________
IN THE MATTER OF:
__________________________
Petitioner,
v.
_________________ County Prosecutor
and The Commissioner for the Indiana
Bureau of Motor Vehicles,
Respondents.
SUMMONS
TO: The Commissioner for the Indiana Bureau of Motor Vehicles, Indiana Government Center
North, Room 402, 100 North Senate Avenue, Indianapolis, Indiana 46204
The above named Petitioner has filed a case in the court stated above for a waiver of re-instatement
fees.
The nature of the suit is waiver of re-instatement fees and is stated in the Petition which is attached
to this document.
If you take no action the court may grant the relief requested.
I request service in the following manner:
the _______________ County Prosecutor by
☐ US Mail or
☐ hand delivery or
☐ electronic transmission or
☐ service by sheriff
Date: ___________________________ ____________________________________
Clerk, __________________ County Court
________________________________
________________________________
________________________________
___________________________________
Page 1 of 1 Approved by the Coalition for Court Access
CCA-MI-0819-2033
STATE OF INDIANA IN THE COURT
COUNTY OF CAUSE NO.______________________________
IN THE MATTER OF:
__________________________
Petitioner,
v.
_________________ County Prosecutor
and The Commissioner for the Indiana
Bureau of Motor Vehicles,
Respondents.
SUMMONS
TO: The ________________________ County Prosecutor, at:
_________________________________________________________________________________
The above named Petitioner has filed a case in the court stated above for a waiver of re-instatement
fees.
The nature of the suit is waiver of re-instatement fees and is stated in the Petition which is attached
to this document.
If you take no action the court may grant the relief requested.
I request service in the following manner:
the _______________ County Prosecutor by
☐ US Mail or
☐ hand delivery or
☐ electronic transmission or
☐ service by sheriff
Date: ___________________________ ____________________________________
Clerk, __________________ County Court
________________________________
________________________________
________________________________
___________________________________
_____
Page 1 of 2 Approved by the Coalition for Court
Access CCA-MC-0619-2031
STATE OF INDIANA ) IN THE COURT
)SS:
COUNTY OF ) CAUSE NO.________________________________
__________________________ Petitioner Date of Birth __________________________
Petitioner, Petitioner Operator License _______________________
v.
_________________ County Prosecutor
and the Commissioner for the Indiana
Bureau of Motor Vehicles,
Respondent.
INDIGENCY AFFIDAVIT
The Petitioner now states:
1. I wish to file this action and I believe that I have a case with merit.
2. I cannot pay any of the filing fees or other costs of this action because I do not have sufficient income
or resources.
3. I cannot pay any of the re-instatement fees required by the BMV because I do not have sufficient
income or resources.
4. I live with _____________________________________________.
5. Our family’s income is $_______________ per month. (Total from below)
Income received each month, before taxes:
Wages ($_________ per hour x _________
hours per month)
$
Unemployment Compensation
$
AFDC/TANF Benefits
$
SSI/SSD Benefits
$
Child Support
$
Other (please describe)
$
Total Income: $
6. We have $_____________ in the bank.
7. Our expenses total $___________ per month. (Total from below)
Expenses spent each month:
Housing (Rent, Contract, or Mortgage)
$
Utilities (Gas, Elective, Water, Phone, etc.)
$
Food
$
Child Care
$
_____
Page 2 of 2 Approved by the Coalition for Court
Access CCA-MC-0619-2031
Medical Bills
$
Transportation
$
Insurance (car, medical, and/or property
$
Child Support
$
Other (please describe)
$
Total Expenses: $
I request that this Court waive all costs of this action and allow me to proceed without the
payment of any filing fees or other costs.
I request that this Court Order the BMV to waive all or part of the re-instatement fees assessed against
me.
I affirm under the penalties of perjury that the foregoing representations are true.
Date: ____________________________ ______________________________________________
Signature
______________________________________________
Printed Name
Page 1 of 1 Approved by the Coalition for Court Access
CCA-MC-0819-2035
STATE OF INDIANA IN THE COURT
COUNTY OF CAUSE NO.______________________________
IN THE MATTER OF:
__________________________
Petitioner,
v.
_________________ County
Prosecutor and The Commissioner
for the Indiana Bureau of Motor
Vehicles,
Respondents.
ORDER SETTING HEARING
A Verified Petition To Waive Re-Instatement Fees has been filed in this Court. The Court now
sets this matter for hearing. The parties must be prepared to present evidence in support of their
petition. Failure to appear may result in matters being decided in your absence.
IT IS SO ORDERED that this matter shall be heard on:
_______________________________________________________________________________.
Dated: _________________________________
Judicial Officer
Distribution:
__________________ County Prosecutor
__________________________________
The Commissioner for the Indiana Bureau of Motor Vehicles
Indiana Government Center North, Room 402
100 North Senate Avenue
Indianapolis, Indiana 46204
__________________________________
__________________________________
__________________________________
__________________________________
Petitioner Date Of Birth ________________________
Petitioner Operator License _____________________
_____
Page 1 of 1 Approved by the Coalition for Court
Access CCA-MC-0619-2034
STATE OF INDIANA ) IN THE _______ COURT
)SS:
COUNTY OF ) CAUSE NO._______________________________
__________________________ Petitioner Date of Birth____________________________
Petitioner, Petitioner Operator License_________________________
v.
_________________ County Prosecutor
and the Commissioner for the Indiana
Bureau of Motor Vehicles,
Respondent.
ORDER WAIVING DRIVER’S LICENSE REINSTATEMENT FEE
The Petitioner, ______________________________, self-represented, having filed their
Verified Petition for Waiver of Driver’s License Reinstatement Fee and this Court having
reviewed the same now GRANTS said petition.
SO ORDERED .
____________________________________
Judicial Officer
DISTRIBUTION:
__________________ County Prosecutor’s Office
Indiana Bureau of Motor Vehicles, Indiana Government Center North, Room 402, 100
North Senate Avenue, Indianapolis, IN 46204
_______________________, Petitioner
, ____________________________________________________
_____
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IN RE THE MATTER OF: ) Petitioner, ) (Indiana Legal Help)

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Completed 31 December 2021

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