IN THE ____________ COURT OF ____________ COUNTY, WEST VIRGINIA
_________________________
Plaintiff or Petitioner
v. Civil Case No. ____________
_________________________
Defendant or Respondent
ORDER:
REVIEW OF ELIGIBILITY
FOR WAIVER OF FEES, COSTS, OR SECURITY
Having reviewed pertinent information related to the financial affidavit and
application dated _____________________ by _____________________________
(name of person alleging eligibility)
for waiver of fees, costs, or security attendant to proceedings and services in this case, this
court finds and hereby ORDERS that ____________________________________
(name of person alleging eligibility)
(initial one) _____ is _____ is not now eligible for such waiver, subject to further order of
this court or to the applicable provisions of Circuit Court Civil Rule 77(e) or Magistrate
Court Civil Rule 22.
ENTER, this __________ day of ________________________________.
________________________________
Circuit Judge/Family Court Judge/Magistrate
SCA-C&M203.03
