Fillable Petition for Waiver of Fees and Costs - (City of Glendale, Wisconsin)

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Petition for Waiver of Fees and Costs - (City of Glendale, Wisconsin)

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BROWSE CITY OF GLENDALE, WISCONSIN (WI) FORMS

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MAP, rev 04/16 Petition for Waiver of Fees and Costs - Affidavit of Indigency and Order
§§757.675(3), 757.69(2m) and 814.29, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
STATE OF WISCONSIN, MUNICIPAL COURT, COUNTY For Official Use
Petition for Waiver of
Fees and Costs -
Affidavit of
Indigency
C
ITY OF GLENDALE
-vs.-
and Order
Case No
.
UNDER OATH, I STATE THAT because of poverty, I am unable to pay any filing and service fees or
, in
this action, proceeding, or appeal, or to give security for those fees, and request waiver of those fees. I am attaching
a copy of my pleading in this matter.
Complete Section 1 if you receive aid from any of the programs
li
ste
d.
If you do not receive aid, complete Section 2
onl
y
.
Section 1.
I currently receive
Supplemental security income.
Relief funded under §59.53(21), Wis. Stats.
Medical assistance.
Food stamps/FoodShare.
Relief funded under public assistance.
Benefits for veterans under §45.40 (1m) or 38 USC 501-562.
Legal representation from a civil legal services program or a volunteer attorney program based on indigency.
Name
of
program:
Other
means-tested public assistance:
My financial situation has has not changed since I became eligible for this program.
If you checked the “has” box, and such changes would make you ineligible for the program(s) if you
applied today, you must complete Section 2.
Section 2.
1. I am am not married.
2
.
I
am am no
t
employed
.
Name o
f
employer
:
3. I earn [Gross pay] $ weekly. every 2 weeks. twice monthly. monthly.
My take-home pay [after taxes and deductions] is $ per pay period.
4. I receive gross monthly income totaling the amount of $ from
Pension
Social security
Unemployment compensation
Disability
Student loans/grants
Ot
her
:
5.
I have the following cash assets:
S
avings accoun
ts:
$
Cash:
$
Checking accoun
ts:
$
Money
owed me
:
$
6.
I have the following other assets:
V
ehicle-
Y
r
./
Make
:
$
Household furnishings:
$
V
ehicle-
Y
r
./
Make
:
$
Equity in real estate:
$
Ot
her individual asse
t
s valued over $200 each
:
$
7. My household consists of myself and others:
Fu
ll name
:
Rela
t
ionship
t
o me
:
Under age 18
Yes
No
Fu
ll name
:
Rela
t
ionship
t
o me
:
Under age 18
Yes
No
Fu
ll name
:
Rela
t
ionship
t
o me
:
Under age 18
Yes
No
Fu
ll name
:
Rela
t
ionship
t
o me
:
Under age 18
Yes
No
Fu
ll name
:
Rela
t
ionship
t
o me
:
Under age 18
Yes
No
MAP, rev 04/16 Petition for Waiver of Fees and Costs - Affidavit of Indigency and Order
§§757.675(3), 757.69(2m) and 814.29, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
P
e
t
i
t
ion
f
or
W
aiver o
f
F
ees and Co
st
s -
Aff
idavi
t
o
f
I
ndigency and
O
rder
P
age 2 o
f
3 Case No
.
8. The other members of my household have gross monthly income totaling the amount of $ from
Wages
Social security
Relief funded under public assistance
Food stamps/FoodShare
Pension
Student loans/grants
Unemployment compensation
Supplemental security income
Disability Relief funded under §59.53(21), Wisconsin Statutes Support/maintenance
Other:
9. I have the following debts: Amount: Monthly Payment:
a.
Mortgage/Rent
$
b.
Auto loan
$
c.
Credit cards
$
d.
Ot
her
:
$
e.
$
10. I have the following unusual expenses, other than ordinary living expenses:
MUN
I
C
IPA
L C
O
UR
T
SEAL
I understand that if my financial situation changes,
I must notify the court immediately.
S
ignature
Print or Type Name
Date of
B
ir
t
h
A
ddress
Phone Number
D
at
e
THE COURT FINDS AND ORDERS:
This petition is
1.
GRANTED because the court finds the petitioner is currently indigent. The action may be commenced without
payment of filing fees. The sheriff shall serve all necessary documents without payment of service fees. The
petitioner may be required to pay filing and services fees if the court later determines the petitioner has the ability to
pay.
2. GRANTED for waiver of . The petitioner may be required to
pay fees if the court later determines the petitioner has the ability to pay.
3. DENIED because the court finds the petitioner is not indigent, but is currently not able to pay filing or service fees.
This action may be filed by the Clerk and all necessary documents may be served by the sheriff without prepayment
of fees. Such fees must be paid no later than
.
4. DENIED because the court finds
petitioner is not indigent.
the allegation of poverty to be untrue.
petitioner
has not
stated
a
meritorious claim, defense,
or
appeal
upon
which the court
may
gra
nt
r
e
lie
f
.
BY THE C
O
UR
T
:
DISTRIBUTION:
1. Original- Clerk of Municipal Court
Municipal Court Judge
D
at
e
MAP, rev 04/16 Petition for Waiver of Fees and
Costs-
Affidavit of
lndigency
and Order
§§757.675(3), 757.69(2m) and 814.29, Wisconsin
Statutes
This form shall not be modified. It may be
supplemented
with additional
material.
Petition
for
Waiver
of
Fees
and
Costs-
Affidavit
of
lndigency
and
Order
Page
3
of
3
Case
No.
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Petition for Waiver of Fees and Costs - (City of Glendale, Wisconsin)

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Completed 10 February 2021

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