INSTRUCTIONS FOR FEE WAIVER
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- Lillian Myra Edwards
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1 INSTRUCTIONS FOR FEE WAIVER 1. After you have completed the fee waiver form, take it to a notary public the form must be notarized. NOTE: Make sure your phone number is at the top of the first page. 2. Take this form to the Family Court Commissioner's office for review. A. If you are mailing the form, send it to: Outagamie County Government Center Attn. Family Court Commissioner 320 S. Walnut Street Appleton, WI Their telephone number is (920) Please call to find out if it's ready to be picked up. B. If you are dropping the form off: You can wait for the Family Court Commissioner to review it if he/she is not in a court hearing. If you leave the waiver at the Family Court Commissioner's office you will need to call (920) or check back the following day. 3. The Family Court Commissioner will indicate on the form whether or not you qualify for a waiver of fees, and if so the amount you are to pay to the Clerk of Courts. NOTE: WAIVER IS VOID 90 DAYS AFTER SIGNED BY THE COURT
2 PHONE: CIRCUIT COURT STATE OF WISCONSIN FAMILY COURT BRANCH OUTAGAMIE COUNTY Petitioner: _ Address: _ Request for Waiver _ of Family Court Mediation Fees -vs- Respondent: _ Case No. Address: AFFIDAVIT Under oath I swear or affirm that: 1. I am requesting Family Court Program services for: Mediation Court Ordered Study 2. Because of my poverty, I am unable to pay the Family Court Program fee. 3. I have no source of income except (i.e., wages, job, child support, unemployment compensation): 4. My gross monthly income from all sources is. (Attach wage statements for last 8 weeks) 5. I own no property of value except: 6. I live with (please name persons and their relationship to you): 7. There is no other source of income in my household except (list monthly income and source of income of each member of your household.) If you are unable to obtain this information, your attached financial disclosure must contain only those expenses for which you are responsible. For instance, if someone else pays the rent, do not put it down as an expense.
3 8. I have not requested any other waiver of Family Court Services fees except: 9. The attached financial disclosure statement is true and correct to the best of my knowledge. Print Name Signature Subscribed and sworn to before me this day of, 20. Notary Public, State of Wisconsin My commission expires ORDER The above request for waiver of Family Court Services fees is denied. OR The above request for waiver of Family Court Services fees is partially approved. must pay $. IT IS ORDERED that the Mediation/Study may be commenced immediately. Services shall be provided upon payment of the requested fee. IT IS FURTHER ORDERED that if the Court subsequently determines it is appropriate to recover fees for the services pursuant to Section , either or both of the parties to this action may be ordered to pay these fees at the conclusion of the action. Dated this day of, 20. BY THE COURT: Family Court Commissioner
4 STATE OF WISCONSIN FAMILY COURT BRANCH OUTAGAMIE COUNTY FAMILY COURT COMMISSIONER In Re the Marriage/Paternity of:, (Petitioner) (Joint Petitioners) -and- FINANCIAL DISCLOSURE Case No., (Respondent) NOTE: This statement must be filed with the Family Court Commissioner before or at the time of the hearing. Failure by either party to complete, present, and file this form as required will authorize the Court or Hearing Officer to accept the statement of the other party as the basis for its decision. Any false statement made hereon shall subject you to the penalty for perjury and may be considered a fraud upon the Court. Husband: Address: Soc. Sec. No.: Birthdate: Employer: Occupation: Wife: Address: Soc. Sec. No.: Birthdate: Employer: Occupation: Children: Date of Birth: Age: With whom are children living: I. INCOME (Attach copies of wage statements from your last eight weeks earnings) Husband Wife A. GROSS MONTHLY INCOME: Employment: (Multiply weekly Income by 4.3 and bi-weekly income by 2.15) Other: (AFDC, Social Security, Pensions, Disability, Unemployment, Interest, Dividends, Rents, Child Support from prior marriage, etc.) (Please circle source of income.) B. MONTHLY DEDUCTIONS Taxes Social Security Insurance Union Dues Retirement Credit Union Others NET MONTHLY INCOME (Subtract Total B from Total A) II. MONTHLY EXPENSES Rent or Mortgage (taxes and insurance) Food Utilities Telephone Clothing Laundry Medical Dental Insurance (exclude payroll deductions) Child Care Auto Expense (gas, insurance, etc.) Auto Payments Debts (enter total from III Debts) Miscellaneous
5 III. DEBTS Creditor Purposes Original Amount Balance Monthly Payment IV. ASSETS A. REAL ESTATE (If space is insufficient, attach separate schedule. Address Appraised Value Mortgage or Lien Net Value B. MOTOR VEHICLES Type Present Value Mortgage or Lien Who Uses C. CASH AND DEPOSIT ACCOUNTS Bank or Savings & Loan Type Amount D. LIFE INSURANCE Company Premiums Face Amount Beneficiaries Type/Policy Cash Value E. RETIREMENT ANNUITIES OR PROFIT SHARING ACCOUNTS F. STOCKS & SECURITIES (List name, number of shares and value.) G. OTHER ASSETS: (Include valuable collections such as coins, stamps, guns sporting and other equipment, mortgages or notes receivable, interests in Trusts, wills, contract rights, judgments, livestock and pets.) H. HOUSEHOLD FURNITURE: FURNISHINGS & APPLICANCES PRESENT VALUE. Subscribed and sworn to before me this day of, 20. Notary Public, State of Wisconsin My commission expires Signature
INSTRUCTIONS FOR FEE WAIVER
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