Fillable STATE OF INDIANA IN THE SMALL CLAIMS COURT (City of Oakland)

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STATE OF INDIANA IN THE SMALL CLAIMS COURT (City of Oakland)

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Form SC-102 Last revised 01/14/13 (REVERSE)
The Petitioner states:
1. I wish to file this action and I believe that I have a case with merit.
2. I cannot pay the filing fees or other costs of this action because I do not have sufficient income.
3. My income is $_______________ per month. (Income Total from below)
(Income received each month, before taxes.)
Wages ($_____ per hour x _____ hours per month) _____________
Unemployment compensation _____________
AFDC / TANF benefits _____________
SSI / SSD benefits _____________
Child support _____________
Other (describe: ____________________________) _____________
= Income Total _____________
4. My expenses total $ _________ per month. (Expense Total from below)
(Expenses each month)
Housing (Rent, Contract, or Mortgage) _____________
Utilities (Gas, Electric, Water, etc.) _____________
Food _____________
Child care _____________
Medical costs _____________
Transportation _____________
Insurance (medical, car, and/or property) _____________
Child support _____________
Other (describe: ____________________________) _____________
=Expense Total _____________
CONTINUE TO NEXT PAGE
Verified Motion for waiver of filing fees & cost(s)
STATE OF INDIANA
COUNTY OF MARION
)
) SS:
)
_
____________________________________
Plaintiff,
vs.
_
______________________________________
_
Defe
ndant.
Cause No. 49- ___ - __ - SC- .
IN THE SMALL CLAIMS COURT OF
_____________
_____________ Township
____________________________________________
____________________________________________
____________________________________________
____________________________________________
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Form SC-102 Last revised 02/06/13 (REVERSE)
5. My assets total $ ____________. (Asset Total from below)
I have $ _________ in the bank.
This real estate is titled in my name and worth:
A.________________________ _____________
B.________________________ _____________
Other property that I own that is valued at over $500 (E.g., car) :
A.________________________ _____________
B.________________________ _____________
= Asset Total _____________
6. I am being represented by an attorney of an organization (such as Indiana Legal Services, Inc.
and Neighborhood Christian Legal Clinic) that uses generally accepted standards of poverty to
determine eligibility for its services.
The organization is: __________________________________________________________ .
I request that this Court waive all or part of the filing fee and other cost(s), consistent with Rule
LR49-SC00-202, and allow me to proceed with this action.
I affirm under the penalties of perjury of the State of Indiana that the above statements are true
and accurate.
________________________________
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STATE OF INDIANA IN THE SMALL CLAIMS COURT (City of Oakland)

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Completed 26 October 2021

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