Fillable Supreme Court Court of Appeals Denver Juvenile Court (Colorado Judicial Branch)

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Supreme Court Court of Appeals Denver Juvenile Court (Colorado Judicial Branch)

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Page 1 of 3
JDF 205 R10/15 MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FINANCIAL AFFIDAVIT
©2013, 2014 Colorado Judicial Department for use in the Courts of Colorado
Supreme Court Court of Appeals Denver Juvenile Court Denver Probate
Court County Court District Court ____________________ County, Colorado
Court Address:
Plaintiff/Petitioner:________________________________________
v.
Defendant/Respondent: __________________________________
__________________________________________________________________
Attorney or Party Without Attorney: (Name & Address)
Phone Number:
Atty. Reg. #:
COURT USE ONLY
_______________________________
Case Number:
Courtroom:
MOTION TO: FILE WITHOUT PAYMENT OF FILING FEE WAIVE OTHER COSTS OWED TO THE
STATE AND SUPPORTING FINANCIAL AFFIDAVIT
I, _____________________________________ respectfully move the Court for an order to waive the following filing fee(s):
complaint petition answer response motion to modify other: __________________ and as grounds state that I am
without funds, have no adequate funds available, and have a meritorious claim.
All items must be fully completed. Print or type neatly. If an item does not apply, please write “N/A”
Name of Applicant
Last Name
First Name
MI
Street Address (Include Apt. # if applicable)
___________________________________________________________________________________________________________
_______________________________________________________________________ ________________ ____________
City State Zip Code
Own Rent Home Phone #: _____________________
Social Security #
Date of Birth
Most Recent Employer: ____________________________________________________________________________
Work Address: ___________________________________________________________________________________
Work Phone #: ( ) _______________________________
Dates Employed: ___________________________________
Hours/Week: _______Pay Rate: $ _____________ Weekly Bi-weekly Monthly Annual Other:_____________
Name of Other Responsible Party(Spouse, Partner, Parent, Other Persons in Household)
Last Name
First Name
MI
Street Address (Include Apt. # if applicable)
___________________________________________________________________________________________________________
_______________________________________________________________________ ___________________ ____________
City
State Zip Code
Own Rent Home Phone #: ____________________
Social Security #
Driver's Lic. # & State
Date of Birth
Most Recent Employer: ____________________________________________________________________________
Work Address: ___________________________________________________________________________________
Work Phone #: ( ) _______________________________
Dates Employed: ___________________________________
✔
✔
Page 2 of 3
JDF 205 R10/15 MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FINANCIAL AFFIDAVIT
©2013, 2014 Colorado Judicial Department for use in the Courts of Colorado
IF ADDITIONAL SPACE IS NEEDED TO PROVIDE COMPLETE INFORMATION, ATTACH A SEPARATE PAGE.
Gross Monthly Income (See Information on page 3)
Monthly Expenses (See Information on Page 3)
Self (wages, salary, commission)
$
Rent or Mortgage
$
Spouse/Partner, Other Household
Members
$
Groceries
$
Parents (if same household)
$
Utilities
$
Unemployment Benefits
$
Clothing
$
Social Security/Retirement Funds
$
Maintenance/Alimony and/or Child Support
$
Maintenance/Alimony
$
Medical/Dental
$
Other Income (identify)
$
Other Expenses (identify)
$
Other Income (identify)
$
Other Expenses (identify)
$
Total Income
$
Total Expenses
$
Cash on Hand (Cash you are carrying
or which is stored at home, etc.)
$
Credit Cards: (Show type and balance owed)
Type:______________________ Balance $____________
Type:______________________ Balance $____________
Checking Account Balance
$
Name/Address of Bank:
Savings Account Balance
$
Name/Address of Bank:
Stocks, Bonds, or other Investments
Held Balance
$
_______________ ________________________________
Type of Investment Name/Location of Company/Corporation
________________ ________________________________
Vehicles Owned (Autos, boats,
recreational vehicles, etc.) - Estimate
Value
$
Year _______Model ____________License Plate__________
Year _______Model ____________License Plate__________
House(s) or other Property
Estimate Value
$
Amount owed $ ____________Year Purchased__________
I swear under penalty of perjury that all information provided is true and complete. In addition, if requested I will
provide three (3) months of bank statements and pay stubs or other comparable proof of income status. I authorize
the Court to make any necessary contacts to verify the information.
Signature:______________________________________________ Date:________________
Hours/Week: _________Pay Rate: $ ______________Weekly Bi-weekly Monthly Annual Other:_____________
Marital Status: Single Married Partner in a Civil UnionDivorced/Civil Union Dissolved Separated
Widowed
Number in Household: (including yourself) ________
Identify Members:
_______________________________________________ __________ ______________________________
Name Age Relationship
_______________________________________________ __________ ______________________________
Name Age Relationship
0.00
0.00
Page 3 of 3
JDF 205 R10/15 MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FINANCIAL AFFIDAVIT
©2013, 2014 Colorado Judicial Department for use in the Courts of Colorado
MOTION TO FILE WITHOUT PAYMENT SUPPORTING FINANCIAL
AFFIDAVIT, AND SUPPORTING DOCUMENTATION REQUESTED
General Information
It is important that you accurately complete all sections of this form as appropriate based on
your personal circumstances. If a section does not apply, please write N/A.
A. Gross Monthly Income. Includes income from all members of the household who contribute
monetarily to the common support of the household.
Income categories to include:
Wages, including tips, salaries, commissions, payments received as an independent contractor
for labor or services, bonuses, dividends, severance pay, pensions, retirement benefits,
royalties, interest/investment earnings, trust income, annuities, capital gains, unemployment
benefits, Social Security Disability (SSD), Social Security Supplemental Income (SSI),
Workman’s Compensation Benefits, and alimony.
Note: Income from roommates should not be considered if such income is not commingled in accounts
or otherwise combined with the applicant’s income in a fashion which would allow the applicant
proprietary rights to the roommate’s income.
Income categories do not include:
TANF payments, food stamps, subsidized housing assistance, veteran’s benefits earned from a
disability, child support payments, or other public assistance programs.
B. Liquid Assets. Includes cash on hand or in accounts, stocks bonds, certificates of deposit, equity,
and personal property or investments which could readily be converted into cash without
jeopardizing the applicant’s ability to maintain home and employment.
Expenses. Nonessential items such as cable television, club memberships, entertainment, dining out,
alcohol, cigarettes, etc., shall not be included. Allowable expense categories are listed on JDF 205.
If you are applying to have your filing fee waived you may be asked to
supply:
Copies of the previous three months bank statements, including checking and savings. DO NOT provide
originals.
Copies of the previous three months pay stubs and/or proof of income must be included. DO NOT
provide originals.
JDF 206 R6-12 FINDING AND ORDER CONCERNING PAYMENT OF FILING FEES
© 2012 Colorado Judicial Department for use in the Courts of Colorado
County Court District Court Denver Juvenile Court Denver Probate Court
_______________________________________ County, Colorado
Court Address:
Plaintiff/Petitioner: ____________________________________________
v.
Defendant/Respondent/Co-Petitioner: ______________________________
COURT USE ONLY
Case Number:
Division Courtroom
FINDING AND ORDER CONCERNING
PAYMENT OF FILING FEES
Name of Party filing Motion: ________________________________ on __________________ (Date).
Upon review of the attached Motion, the above party is:
Eligible to proceed without payment of the following filing fee(s):
complaint petition answer
response motion to modify other: _______________________
Eligible to have the filing fee of $____________ paid in two three payments, with the first payment due
by_____________(date) and the final payment due by__________________(date).
Not Eligible to proceed. Party is responsible for payment of the filing fees.
Date: _________________________ _____________________________________________
Signature of Eligibility Investigator, Clerk of Court, Judge/Magistrate
_______________________________________________________________________________________________
ORDER
The Court has reviewed the Motion (JDF 205) and so orders:
As indicated above.
The specified party is ordered to pay $____________ by _____________________ (Date) to cover filing
fees.
Other
The Court finds that by allowing a party to proceed with a payment plan, the party has agreed to pay the
fee as listed above. Failure to pay will result in collection against the party. Costs associated with
collection will be assessed.
A subsequent motion to proceed without payment of filing fees must be filed upon order of the court or anytime
the case is re-opened.Pursuant to §13-16-103, C.R.S., in the event the party who receives a waiver of costs
prosecutes or defends an action or proceeding successfully, there shall be a judgment entered in his/her favor in
the amount of the court costs and the party shall, upon collecting such court costs, remit them to the Court.
Date: __________________________ _____________________________________________
Judge Magistrate
✔
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Supreme Court Court of Appeals Denver Juvenile Court (Colorado Judicial Branch)

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Completed 12 March 2021

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