Fillable PC 184 (State of Connecticut, Office of the Probate Court Administrator)

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PC 184 (State of Connecticut, Office of the Probate Court Administrator)

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BROWSE STATE OF CONNECTICUT, OFFICE OF THE PROBATE COURT ADMINISTRATOR (CT) FORMS

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Request/Order
Waiver of Fees (Petitioner)
PC-184 REV. 7/19
CONNECTICUT PROBATE COURTS
Request/Order Waiver of Fees (Petitioner)
PC-184 Page 1 of 3
RECEIVED:
Instructions: 1) A petitioner in a probate matter may use this form to establish that he or she is indigent and unable to
pay probate fees and expenses for which the petitioner may be responsible. The petitioner must include
both the petitioner’s information and information for the petitioner’s household. A household is one or
more individuals who rely on themselves or one another for support.
2) A fiduciary or attorney may file this form on behalf of a person they represent. The fiduciary or attorney
should include only the petitioner’s household information and not the fiduciary or attorney’s
information.
3) Include with this form documentation substantiating the reported assets and income. For example, pay
stubs from employment and evidence of public assistance.
4) There is a rebuttable presumption that the petitioner is indigent if: (a) he or she receives public
assistance OR (b) the annual income of the petitioner’s household is 125% or less of the federal poverty
level after taxes, other mandatory payroll deductions and child care expenses.
5) Type or print in ink. Use an additional sheet, or PC-180, if more space is needed.
Probate Court Name
District Number
In the Matter of
Petitioner (Name and address) Type of Matter
The undersigned represents that:
1)
Total number of people in the household, including the petitioner:
2)
Net monthly household income from employment after taxes and mandatory payroll deductions:
3)
Other monthly household income:
a)
Public assistance includes: state-administered general assistance; temporary family
assistance; aid to the aged, blind and disabled; supplemental nutrition assistance; and
supplemental security income also known as SSI.
b)
c)
d)
e)
Total other monthly household income (Items 3a through 3e above)
Total net monthly household income (Items 2 and 3 above)
RESET
Request/Order
Waiver of Fees (Petitioner)
PC-184 REV. 7/19
CONNECTICUT PROBATE COURTS
In the Matter of
Request/Order Waiver of Fees (Petitioner)
PC-184 Page 2 of 3
The undersigned further represents that:
1)
Estimated value of household assets:
a)
b)
c)
d)
e)
f)
Total net value of household assets (Items 1a through 1f above)
2)
Current household liabilities/debts (excluding any above mortgages/loans):
a)
b)
Total current household liabilities (Items 2a through 2b above)
3)
Estimated reoccurring monthly household expenses:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
Total reoccurring monthly household expenses (Items 3a through 3k above)
The undersigned requests that the court grant a waiver of fees and expenses in the above matter for which the
petitioner may be responsible because the petitioner is indigent and unable to pay the fees and expenses.
The representations made in this petition are made under penalty of false statement.
Signature of Petitioner or R
epresentative
Type or Print Name
Title or Relationship (if applicable)
Date
Request/Order
Waiver of Fees (Petitioner)
PC-184 REV. 7/19
CONNECTICUT PROBATE COURTS
In the Matter of
Request/Order Waiver of Fees (Petitioner)
PC-184 Page 3 of 3
For Court Use Only
Probate Court Name
District Number
PRESIDING JUDGE: Hon.
The foregoing request having been presented to the court, the COURT FINDS that the petitioner:
is in
digent and entitled to a waiver of fees and expenses as requested above.
is not indigent.
WHEREFORE, it is ORDERED and DECREED that the request for waiver of fees and expenses is:
GRANTE
D. DENIED.
Dated at:
, Connecticut, on
[Month, Day, Year]
Judge
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PC 184 (State of Connecticut, Office of the Probate Court Administrator)

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Completed 20 July 2020

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