Fillable STATE OF MICHIGAN CASE NO. and JUDGE JUDICIAL (County of Otsego)

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STATE OF MICHIGAN CASE NO. and JUDGE JUDICIAL (County of Otsego)

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U.S.A. forms for County of Otsego

BROWSE COUNTY OF OTSEGO (MI) FORMS

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Plaintiff/Petitioner’s name, address, and telephone no.
v
Defendant/Respondent’s name, address, and telephone no.
Plaintiff/Petitioner’s attorney, bar no., address, and telephone no. Defendant/Respondent’s attorney, bar no., address, and telephone no.
In the matter of
STATE OF MICHIGAN
JUDICIAL DISTRICT
JUDICIAL CIRCUIT
COUNTY PROBATE
FEE WAIVER REQUEST
CASE NO. and JUDGE
Court address Court telephone no.
JIS CODE: OSF
Approved, SCAO
Form MC 20, Rev. 10/19
MCR 2.002
Page 1 of 2
Distribute form to:
Court
Applicant
Other parties
Friend of the court (when applicable)
Instructions: Complete this form and file it with the court. After you receive a decision on your request, you must serve your
request and the decision on the other party(ies).
I request a waiver of my filing fees for the following reason: (Check 1, 2, or 3)
1. I receive the following type(s) of public assistance because of indigence:
Food Assistance Program through the State of Michigan (also known as FAP or SNAP)
Medicaid (including Healthy Michigan, CHIP, and ESO)
Family Independence Program through the State of Michigan (also known as FIP or TANF)
Women, Infants, and Children benefits (WIC)
Supplemental Security Income through the federal government (SSI)
Other means-tested public assistance:
My public assistance case number(s) (if any) is
Write “none” if no case number. Do not write your SSN.
.
2. I am represented by a legal services program or I receive assistance from a law school clinic because
of indigence. The name of the legal services program or law school clinic is
.
3. I am unable to pay the fees and I did not check item 1 or 2 above.
My gross household income is $
every
Week/Two weeks/Month/Year
.
The number of people in my household is
.
My source of income is
.
List assets and their worth, such as bank accounts. If you need more space, attach a separate sheet.
List obligations and how much you pay, such as rent or other debts. If you need more space, attach a separate sheet.
I declare under the penalties of perjury that this request has been examined by me and that its contents are true to the best
of my information, knowledge, and belief.
Date
Signature
46th
800 Livingston Blvd. Ste 1A Gaylord, MI 49735
(989)731-7450
Fee Waiver Request (10/19)
Page 2 of 2
Case No.
1. Payment of filing fees is waived.
Signature of court clerk and date
IT IS ORDERED:
1. Payment of filing fees is waived because:
a. Your gross household income is under 125% of the federal poverty guidelines.
b. Your gross household income is above 125% of the federal poverty guidelines, but payment of
the fees would constitute a financial hardship for you.
c. Other:
If you become able to pay the fees before this case is resolved, you must notify the court.
2. The fee waiver request is denied because:
a. Your gross household income is above 125% of the federal poverty guidelines and payment of
the fees would not constitute a financial hardship for you.
b. Other:
Judge/Magistrate (when authorized) signature and date
IF YOUR REQUEST WAS DENIED: To continue your case and preserve your filing date, you have 14 days from the issue
date below to pay the filing fees or request a review. To request a review, fill out a Request for Review of Denied Fee Waiver
(form MC 114) and file it with the court.
Issue date (completed by clerk)
CLERK WAIVER
ORDER
NOTICE
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STATE OF MICHIGAN CASE NO. and JUDGE JUDICIAL (County of Otsego)

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Completed 9 August 2020

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