MC 20 (12/18) FEE WAIVER REQUEST MCR 2.002
Plaintiff’s/Petitioner’s attorney, and bar no. Defendant’s/Respondent’s attorney and bar no.
Probate In the matter of
Original - Court
1st copy - Applicant
2nd copy - Other party
3rd copy - Friend of the court
JIS CODE: OSF
STATE OF MICHIGAN
FEE WAIVER REQUEST
Court address Court telephone no.
Instructions: Complete the form and file it with the clerk. After you receive a decision on your request, you
must serve your request and the decision on the other party.
I request a waiver of my filing fees for the following reason: (Check 1, 2, or 3)
1. I receive the following type(s) of public assistance because of indigence:
Food Assistance Program through the State of Michigan (also known as FAP or SNAP)
Medicaid (including Healthy Michigan, CHIP, and ESO)
Family Independence Program through the State of Michigan (also known as FIP or TANF)
Women, Infants, and Children benefits (WIC)
Supplemental Security Income through the federal government (SSI)
Other means-tested public assistance:
My public assistance case number(s) (if any) is
Do not include your Social Security number.
2. I am represented by a legal services program or I receive assistance from a law school clinic because
of indigence. The name of the legal services program or law school clinic is
3. I am unable to pay the fees.
My gross household income is $
The number of people in my household is
My source of income is
List assets and their worth, such as bank accounts. If you need more space, attach a separate sheet.
List obligations and how much you pay, such as rent or other debts. If you need more space, attach a separate sheet.
I declare under the penalties of perjury that this request has been examined by me and that its contents
are true to the best of my information, knowledge, and belief.
FOR CLERK USE ONLY: Payment of filing fees is waived.
Signature of court clerk