JDF 205 Motion to file without payment and supporting financial affidavit FINAL 10 15

Transcript

1   Court of Appeals  Denver Juvenile Court  Denver Probate Supreme Court   District Court ____________________ County, Colorado County Court Court Court Address: Plaintiff/ Petitioner:________________________________________ v. ______________________________ Respondent: ____ Defendant/ __________________________________________________________________ Attorney or Party Without Attorney: (Name & Address) COURT USE ONL Y __ _____________________________ Phone Number: Case Number: Atty. Reg. #: 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  ans wer  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 First Name MI Last Name (Include Apt. # if applicable) Street Address ___________________________________________________________________________________________________________ _____________________________________ __________________________________ ________________ ____________ 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: ___________________________________  ther:_____________ O  Hours/Week: _______Pay Rat e: $ _____________  Weekly  Bi - weekly  Monthly Annual Name of O ( Spouse, Partner, Parent, Other Persons in Household ) ther Responsible Party Last Name First Name MI Street Address ( Include Apt. # if applicable) _____________________________________ ______________________________________________________________________ _______________________________________________________________________ ___________________ ____________ City State Zip Code  Own  Rent Home Phone #: ____________________ Date of Birth Driver's Lic. # & State Social Security # Most Recent Employer: ____________________________________________________________________________ _________________________________________________________ Work Address: __________________________ Work Phone #: ( ) _______________________________ Dates Employed: ___________________________________  weekly - Bi  Weekly  Hours/Week: _________Pay Rate: $ ______________ her:_____________ Ot  Annual  Monthly 1 Page of 3 IT ANCIAL MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FIN AFFIDAV 205 JDF R10/15

2 Marital Status: Separated  /Civil Union Dissolved Divorced   Civil Union Partner in a  Married   Single  Widowed ________ (including yourself) Number in Household: Identify Members: _______________________________________________ __________ ______________________________ Age Relationship Name __________ ______________________________ _______________________________________________ Age Name Relationship enses (See Information on Page 3) Monthly Exp Gross Monthly Income (See Information on page 3) Self (wages, salary, commission) $ Rent or Mortgage $ $ $ Other Household Partner, Spouse/ Groceries Members Parents (if same household) $ Utilities $ Clothing $ $ Unemployment Benefits Social Security/Retirement Fund s $ Maintenance/Alimony and/or Child Support $ Medical/Dental $ Maintenance/Alimony $ $ Other Income (identify) $ Other Expenses (identify) $ Other Expenses (identify) $ Other Income (identify) $ $ Total Expenses Total Income ( Cash on Hand Cash you are carrying (Show type and balance owed) : Credit Cards $ or which is stored at home, etc.) $ ____________ Type:______________________ Balance Type :______________________ Balance $ ____________ Checking Name/Address of Bank Account Balance : $ Saving Name/Address of Bank: s Account Balance $ Stocks, Bonds, or other Investments _______________ ________________________________ $ Held Balance t Type of Investmen Name/Location of Company/Corporation ________________ ________________________ ________ Vehicles Owned ( Autos, boats, Year _____ Plate__________ Model ____________License __ $ recreational vehicles, etc .) - Estimate Value Year _______Model ____________License Plate__________ House(s) or other Property $ Year Purchased __________ Amount o wed $ ____________ Estimate Value IF ADDITIONAL SPACE IS NEEDED TO PROVIDE COMPLETE INFORMATION, ATTACH A SEPARATE PAGE. In addition, if requested I will I swear under penalty of perjury that all information provided is true and complete. I authorize pr ovide three (3) months of bank statements and pay stubs or other comparable proof of income status. the Court to make any necessary contacts to verify the information. ______________ Signature:________________________________ Date:________________ 2 of 3 Page ANCIAL MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FIN R10/15 AFFIDAV 205 JDF IT

3 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 If a section does not apply, please write N/A. your personal circumstances. Gross Monthly Income. A. Includes i ncome from all members of the household who contribute monetarily to the common support of the household.  include: to tegories Income ca 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 commi ngled 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: ran’s benefits earned from a TANF payments, food stamps, subsidized housing assistance, vete disability, child support payments or other public assistance programs. , B. Liquid Assets cash on hand or in accounts, stocks bonds, certificates of deposit, equity, s clude In . adily be converted into cash without and personal property or investments which could re jeopardizing the applicant’s ability to maintain home and employment. Expenses . Non essential items such as cable television, club memberships, entertainment, dining out, shall not Allowable expense categories are listed on J be includ ed. alcohol, cigarettes, etc., DF 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. • Co pies of the previous three months pay stubs and/or proof of income must be included. DO NOT provide originals. 3 Page of 3 IT ANCIAL MOTION TO FILE WITHOUT PAYMENT OR FILING FEE AND SUPPORTING FIN AFFIDAV 205 JDF R10/15

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