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SUPERIOR COURT OF THE DISTRICT OF COLUMBIA 500 (Superior Court of DC)

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U.S.A. forms for Superior Court of DC

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SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
500 Indiana Ave, NW, Washington, DC 20001
(202) 879-1010 www.dccourts.gov
Super. Ct. Civ. R. 54-II; Super. Ct. Dom. Rel. 54-II;
D.C. Code § 15-712.
Page 1 of 4
DCSC106A 09-2019
Case Caption
Case Number
APPLICATION TO PROCEED WITHOUT PREPAYMENT OF COSTS, FEES, OR SECURITY
(Form 106A In Forma Pauperis)
I, ___________________________________________ am the
Plaintiff/Petitioner
Defendant/Respondent
Guardian
Movant
Intervenor/Proposed Intervenor
Other: ___________________________
I respectfully ask that I not be required to prepay court fees in this case. I cannot do so without substantial
financial hardship to me or my family for the following reason(s):
INCOME
1. I receive the following public benefits:
Temporary Assistance for Needy Families (TANF)
General Assistance for Children (GAC)
Program on Work, Employment and Responsibility (POWER)
Supplemental Security Income (SSI)
If you checked any of the boxes in question 1, you do not need to answer any more questions and may skip
to the “Declaration” on page 3. Otherwise, go to the next question.
For Clerk’s Use Only
This Application has been reviewed and approved by:
Signature
Printed Name
SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
500 Indiana Ave, NW, Washington, DC 20001
(202) 879-1010 www.dccourts.gov
Super. Ct. Civ. R. 54-II; Super. Ct. Dom. Rel. 54-II;
D.C. Code § 15-712.
Page 2 of 4
DCSC106A 09-2019
2. I receive the following benefits:
Interim Disability Assistance
Medicaid or DC Healthcare Alliance
If you checked any of the boxes in question 2, you do not need to answer any more questions and may skip
to the ‘Declaration’ on page 3. Otherwise, you must answer the rest of the questions on this form. If
additional information concerning questions 2-8 is required, you will be notified.
3. My total income over the past 12 months from all sources is $_________________________.
4. I am presently
employed.
unemployed. The last date I worked was ________________, _______.
Month Year
DEPENDENTS
5. How many people depend on you for financial support? ________.
Of these people, how many are minor children or elderly? ________.
ASSETS
6. I have $ __________ in cash, including money in bank accounts.
I own the following vehicles, real estate, or other valuable property:___________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
EXPENSES
7. This is my best estimate of the monthly expenses for me and the people who depend on me for
financial support:
Housing (such as rent, mortgage, taxes, insurance):
Utilities (such as gas, electric, water, phone, internet):
Food and household necessities:
Child-related expenses (such as childcare, diapers):
Health (such as medical, prescriptions, dental, vision, insurance):
Transportation (such as vehicle loan, gas, insurance, metro, buses):
Other debt and expenses:
Total Estimated Monthly Expenses:
SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
500 Indiana Ave, NW, Washington, DC 20001
(202) 879-1010 www.dccourts.gov
Super. Ct. Civ. R. 54-II; Super. Ct. Dom. Rel. 54-II;
D.C. Code § 15-712.
Page 3 of 4
DCSC106A 09-2019
OTHER CIRCUMSTANCES
8. Explain any special circumstances that you want the judge to consider in support of your request,
including any child support orders, large monthly expenses, debts, wage or bank account
garnishments, and/or judgments.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
DECLARATION
I solemnly swear or affirm under criminal penalties for the making of a false statement, which includes
180 days in jail or a $1,000 fine or both, that I have read this Application and that the factual statements
made in it are true to the best of my personal knowledge, information and belief.
__________________________________________
Signature
__________________________________________
Address Line 1
__________________________________________
Address Line 2
__________________________________________
Phone Number
__________________________________________
Date
POINTS AND AUTHORITIES
1. D.C. Code § 15-712.
2. D.C. Code § 22-2405.
3. Civil Rule 54-II, Domestic Relations Proceedings Rule 54-II, and Family Rule R.
4. Adkins v. E.I. Du Pont de Nemours & Co., Inc., 335 U.S. 331 (1948).
5. Harris v. Harris, 137 U.S. App. D.C. 318, 322, 424 F.2d 806 (1970), cert. denied, 400 U.S. 826 (1970)
(“in forma pauperis relief not limited to those who are public charges or absolutely destitute”).
6. Green v. Green, 562 A.2d 1214 (D.C. 1989) (statute “effectuates the fundamental principle that every
litigant should be provided equal access to the courts without regard to financial ability”).
7. Cabillo v. Cabillo, 317 A.2d 866, 866 (D.C. 1974) (per curiam)(reversing denial of in forma pauperis
status and mandating granting of petition where litigant’s income “only slightly above the welfare
standard”).
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SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
500 Indiana Ave, NW, Washington, DC 20001
(202) 879-1010 www.dccourts.gov
Super. Ct. Civ. R. 54-II; Super. Ct. Dom. Rel. 54-II;
D.C. Code § 15-712.
Page 4 of 4
DCSC106A 09-2019
Case Caption
Case Number
ORDER
Upon consideration of the Application to Proceed Without Prepayment of Costs, Fees, or Security filed by
___________________________________________, it is hereby ordered that the Application is:
GRANTED in this Family Court case, and, pursuant to Domestic Relations Rule 54-II(i),
witnesses will be subpoenaed without prepayment of witness fees.
GRANTED in this Civil Division case, and pursuant to Civil Rule 54-II(i), the clerk will attempt
to serve by mail the materials listed in Civil Rule 4(c)(1). Plaintiff/Petitioner is responsible for
service and proof of service if the clerk’s efforts are unsuccessful.
GRANTED in this Probate Division case.
GRANTED in this Tax Division case.
GRANTED in this Criminal Division case.
GRANTED________________________________________________________________
________________________________________________________________________.
DENIED, for the reasons stated on the record in open court and in the presence of the applicant or
applicant’s counsel.
DENIED, for the following reasons:
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________________.
________________ _____________________________
Date Judge
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Completed 15 July 2021

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