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Petitioner v. (Indiana Legal Help)

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Page 1 of 2 Approved by the Coalition for Court Access
CCA-GF-0420-3012
www.indianalegalhelp.org
STATE OF INDIANA IN THE __________________ ______________ COURT
COUNTY OF _________________ CAUSE NO. ________________________________
IN RE THE MATTER OF:
__________________________
Petitioner
v.
__________________________
Respondent
APPEARANCE BY UNREPRESENTED PERSON
1. My name is _________________________________ and in this case I am not represented
by a lawyer.
2. My contact information for receiving legal service of documents and case information as
required by Court Rules is:
Address:
Email address:
☐ I will accept service at the above email address.
Phone:
Fax:
OR, if in a related case, you have used the Attorney General confidential address, you may
check the box below:
☐ Attorney General confidential address
3. This is a _____ case type as defined in Administrative Rule 8(B)(3).
4. There are other cases related to this case: (If yes, please indicate below)
☐ Yes
☐ No
Caption and case number of related cases:
Caption: Case No.:
PRINT
___________________
Page 2 of 2 Approved by the Coalition for Court Access
CCA-GF-0420-3012
www.indianalegalhelp.org
Caption: Case No.:
Caption: Case No.:
Additional information as required by local rule:
Signature
This appearance is filed with a Verified Motion For Fee Waiver. There is no other party
to serve.
Page 1 of 2 Approved by the Coalition for Court Access
CCA-GF-0420-3006
www.indianalegalhelp.org
STATE OF INDIANA IN THE __________________ ______________
COURT
COUNTY OF _________________ CAUSE NO. ________________________________
IN RE THE MATTER OF:
__________________________
Petitioner
v.
__________________________
Respondent
VERIFIED MOTION FOR FEE WAIVER
The Petitioner now states:
1. I wish to file this action and I believe I have a case with merit.
2. I cannot pay any of the filing fees or other costs of this action because I do not have sufficient
income or resources.
3. I live with the following persons who are over eighteen (18) years of age
____________________________________________________________________________________.
4. I live with the following persons who are under eighteen (18) years of age
____________________________________________________________________________________.
5. I am responsible for the financial support of the following people who live in my household
____________________________________________________________________________________.
6. The combined income of all persons I am responsible for supporting is $_________________per
month (total from below).
Income Received Each Month (before taxes)
Wages ($_____________ per hour x _________
hours per month)
$
Unemployment Compensation
$
AFDC/TANF Benefits
$________________
SSI/SSD Benefits
$
Child Support
$
Other (please describe)
$
Total Income
$__________________
7. We have $___________________ in the bank.
8. Our expenses total $___________________ per month. (Total from below).
___________________
Page 2 of 2 Approved by the Coalition for Court Access
CCA-GF-0420-3006
www.indianalegalhelp.org
Monthly Expenses
Housing (Rent, Contract, or Mortgage)
$
Utilities (Gas, Elective, Water, Phone, etc.)
$
Food
$
Child Care
$
Medical Bills
$
Transportation
$
Insurance (Car, Medical, and/or Property)
$
Child Support
$
Other (please describe)
$
Total Expenses
$
I request that this Court waive all costs of this action and allow me to proceed without the
payment of any filing fees or other costs.
There is no other party to serve.
I affirm under penalties for perjury that the foregoing representations and
statements are true.
______________________ ______________________________
Date Signature
______________________________
Printed Name
Page 1 of 1 Approved by the Coalition for Court Access
CCA-GF-0420-3007
www.indianalegalhelp.org
STATE OF INDIANA IN THE __________________ ______________ COURT
COUNTY OF _________________ CAUSE NO. ________________________________
IN RE THE MATTER OF:
__________________________
Petitioner
v.
__________________________
Respondent
ORDER ON FEE WAIVER
The Petitioner, self represented, has filed a Verified Motion For Fee Waiver which the Court
has read and finds should be granted.
IT IS THEREFORE ORDERED that Petitioner may file this case:
☐ Without the pre-payment of any filing fees, costs, security, bond or other expenses; or
☐ Upon the prepayment of $ ___________ which is a portion of the filing fee set by statute. Such
sum must be paid by the Petitioner to the Clerk within the next twenty (20) days.
The Court will determine whether any or additional costs are to be paid at a preliminary or
final hearing in this case.
__________________________________ _________________________________
Date Judicial Officer
Distribution:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
___________________
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Petitioner v. (Indiana Legal Help)

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Completed 31 December 2021

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