STATE OF INDIANA )
) SS:
COUNTY OF DELAWARE )
IN THE DELAWARE CIRCUIT COURT NO.
IN RE THE GUARDIANSHIP OF:
CAUSE NO: 18C0
VERIFIED MOTION FOR FEE WAIVER
The petitioner now states:
  • I wish to file this action and I believe that I have a case with merit.
  • I cannot pay any of the filing fees or other costs of this action because I do not have sufficient income or resources.
  • I live with .
  • Our family’s income is per month. (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
    (please describe)
    Total =
  • We have in the bank.
  • Our expenses total per month. (Total from below)
    (Expenses spent each month)
    Housing (Rent, Contract, or Mortgage)
    Food
    Utilities (Gas, Electric, Water, Phone, etc.)
    Child Care
    Medical Bills
    Transportation
    Insurance (car, medical and/or property)
    Child Support
    Other
    (please describe)
    Total =
I request that this Court waive all costs of this action and allow me to proceed without the payment of any filing fees or other costs.
I affirm under the penalties of perjury that the foregoing representations are true.
Signature