MC 20 (12/18) FEE WAIVER REQUEST MCR 2.002
Plaintiff’s/Petitioner’s name
v
Defendant’s/Respondent’s name
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
(when applicable)
JIS CODE: OSF
STATE OF MICHIGAN
JUDICIAL DISTRICT
JUDICIAL CIRCUIT
COUNTY PROBATE
FEE WAIVER REQUEST
CASE NO.
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 $
every
Week/Two weeks/Month/Year
.
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.
Date
Signature
FOR CLERK USE ONLY: Payment of filing fees is waived.
Date
Signature of court clerk
Fee Waiver Request (12/18)
Case No.
IT IS ORDERED:
1. Payment of filing fees is waived because:
a. The applicant’s gross household income is under 125% of the federal poverty level.
b. Other:
You must notify the court if you become able to pay the fees before this case is resolved.
2. The fee waiver request is denied. To continue your case, you have 14 days from the date of this order
to pay the filing fees or request a review. To request a review, complete and file the request for review
(form MC 114).
The reason for denial is:
Date
Judge Bar no.
ORDER
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