Fillable Request to Waive Court Fees If you are (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Request to Waive Court Fees If you are (Central Council Tlingit and Haida Indian Tribes of Alaska)

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BROWSE CENTRAL COUNCIL TLINGIT AND HAIDA INDIAN TRIBES OF ALASKA (AK) FORMS

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Page 1 of 3
Tlingit & Haida Tribal Court
320 W. Willoughby Ave. Suite 300
Juneau, AK 99801
1-800-344-1432 / 866-532-3558 Fax
Request to Waive Court Fees
If you are getting public assistance, are a low-income person, or do not have enough income to
pay for household’s basic needs and your court fees, you may use this form to ask the court to
waive all or part of your court fees. The court may order you to answer questions about your
finances. If the court waives the fees, you may still have to pay later if:
• You cannot give the court proof of eligibility (Please provide paystubs from employer or
copies of checks from TANF, SSI, or other agency).
• Your financial situation improves during this case.
Name: ________________________________________________________________________
Physical Address: _______________________________________________________________
Mailing Address: _______________________________________________________________
City: ____________________________ State: ______________________ Zip: _____________
Employer: _____________________________________________________________________
Title: _________________________________________________________________________
Employer’s Address: ____________________________________________________________
What fees are you asking to be waived?
______________________________________________________________________________
______________________________________________________________________________
Why are you asking for the court to waive your court fees?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Page 2 of 3
Tlingit & Haida Tribal Court
320 W. Willoughby Ave. Suite 300
Juneau, AK 99801
1-800-344-1432 / 866-532-3558 Fax
Monthly Income
Gross income before deductions: $_______________________
List sources and amount od any other income you her each month, including spousal/child
support, retirement, social security, disability, unemployment, military basic allowance for
quarters (BAQ), veterans payments, dividends, interest, trust income, annuities, net business or
rental income, reimbursement for job-related expenses, gambling or lottery winnings, etc.
1. ___________________________________ $__________________
2. ___________________________________ $__________________
3. ___________________________________ $__________________
4. ___________________________________ $__________________
Total Monthly Income: $__________________
Household income - List all other persons living in your home and their income; include only
your spouse and all individuals who depend in whole or in part on you for support, or on whom
you depend in whole or part for support.
1. Name: _____________________ age: ________ Income: $__________________
2. Name: _____________________ age: ________ Income: $__________________
3. Name: _____________________ age: ________ Income: $__________________
4. Name: _____________________ age: ________ Income: $__________________
Total Monthly Income: $__________________
List any other facts you ant the court to know, such as unusual medical expenses, family
expenses, family emergencies, etc., attach to this form (list here and attach any documentation).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Important: If your financial situation or ability to pay court fees improvise, you must notify
the court within five days.
Page 3 of 3
Tlingit & Haida Tribal Court
320 W. Willoughby Ave. Suite 300
Juneau, AK 99801
1-800-344-1432 / 866-532-3558 Fax
Money & Property - Cash on Hand: $__________________
List financial accounts (bank and amount)
__________________________________ $__________________
__________________________________ $__________________
__________________________________ $__________________
Do you own any cars, boats and other vehicles (please list):
1. _____________________ Value: ________________ Payments: _______________
2. _____________________ Value: ________________ Payments: _______________
3. _____________________ Value: ________________ Payments: _______________
Do you own any real estate (please list):
1. _____________________ Value: ________________ Payments: _______________
2. _____________________ Value: ________________ Payments: _______________
3. _____________________ Value: ________________ Payments: _______________
Other personal property (jewelry, furniture, furs, stocks, bonds, etc.)
1. _____________________ Value: ________________ Payments: _______________
2. _____________________ Value: ________________ Payments: _______________
3. _____________________ Value: ________________ Payments: _______________
Monthly Expenses:
Rent
$
Food/Household
$
Utilities/telephone
$
Clothing
$
Laundry/Cleaning
$
Medical/Dental
$
Insurance
$
Child Care
$
Child Support
$
Transportation
$
Installment Payments
$
Any other monthly payments
$
Total Monthly Expenses:
$
The information I have provided on this form and all attachments are true and correct.
Print Name: ___________________________
Signature: _____________________________ Date: _______________
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Request to Waive Court Fees If you are (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Completed 18 November 2021

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