IN THE ____________ COURT OF ____________ COUNTY, WEST VIRGINIA
______________________
Plaintiff or Petitioner
v. Civil Case No. ____________
______________________
Defendant or Respondent
MOTION FOR REVIEW:
ELIGIBILITY FOR WAIVER OF FEES, COSTS, OR SECURITY
I hereby move for a review of my eligibility for waiver of fees, costs, or security
attendant to proceedings or services in this case and a ruling as provided by law.
Date: _________________ Signature _____________________________
Name (print clearly) _____________________
SCA-C&M202.03