GeneralFeeWaiver 0420INSTRUCTIONS-4.21.23

SELECT THE COURT TYPE
IF YOU KNOW IT. IF NOT,

LEAVE BLANK
STATE OF INDIANA IN THE COUNTY NAME

__________________ ______________ COURT
COUNTY NAME
COUNTY OF _________________ LEAVE BLANK
CAUSE NO. ________________________________
IN RE THE MATTER OF:
YOUR NAME
__________________________
Petitioner
v.
OTHER PERSON'S NAME. IF THERE IS NO OTHER PERSON
INVOLVED I N YOUR CASE (LIKE A NAME CHANGE) JUST
__________________________
LEAVE THIS BLANK
Respondent
APPEARANCE BY UNREPRESENTED PERSON
1. YOUR NAME
My name is _________________________________ and in this case I am not represented
by a lawyer.
2. My contact information for receiving legal service of documents and case information as
required by Court Rules is:
Address: YOUR ADDRESS
SELECT THIS BOX

ONLY IF YOU WANT
THE COURT TO
COMMUNICATE WITH
YOU ONLY BY EMAIL Email address: YOUR EMAIL ADDRESS
AND YOU CAN CHECK
YOUR EMAIL EVERY
☐ I will accept service at the above email address.
DAY Phone:
Fax:
IF YOU ARE USING
OR, if in a related case, you have used the Attorney General confidential address, you may
THE ATTORNEY check the box below:
GENERAL'S ☐ Attorney General confidential address
CONFIDENTIAL
ADDRESS, CHECK INSERT CASE TYPE PER ADMIN RULE 8(B)(3), OR LEAVE BLANK
THIS BOX 3. This is a _____ case type as defined in Administrative Rule 8(B)(3).
4. There are other cases related to this case: (If yes, please indicate below)
SELECT THE BOX THAT IS TRUE ☐ Yes
☐ No
Caption and case number of related cases:

IF THERE IS A RELATED CASE, PLEASE COMPLETE THIS INFORMATION
Caption: Case No.:
Page 1 of 2 Approved by the Coalition for Court Access

CCA-GF-0420-3012
www.indianalegalhelp.org
Caption: Case No.:
Caption: Case No.:
Additional information as required by local rule:

IF ADDITIONAL INFORMATION IS REQUIRED BY LOCAL RULE, PUT THAT
INFORMATION HERE.
SIGN HERE AFTER YOU PRINT THIS FORM

Signature
This appearance is filed with a Verified Motion For Fee Waiver. There is no other party
to serve.

CCA-GF-0420-3012
STATE OF INDIANA IN THE __________________ ______________
COURT
COUNTY OF _________________ CAUSE NO. ________________________________
__________________________ FOR THE SECTION ABOVE THE DOTTED LINE, LOOK AT

Petitioner THE FIRST FORM YOU FILLED OUT AND COPY THE
INFORMATION HERE.
v.
__________________________
Respondent
------------------------------------------------------------------------------------------------------------------------------------
VERIFIED MOTION FOR FEE WAIVER
The Petitioner now states:
1. I wish to file this action and I believe I have a case with merit.
2. I cannot pay any of the filing fees or other costs of this action because I do not have sufficient
income or resources.
3. I live with the following persons who are over eighteen (18) years of age
NAMES OF THE PEOPLE YOU LIVE WITH WHO ARE OVER 18 YEARS OLD
____________________________________________________________________________________.
4. I live with the following persons who are under eighteen (18) years of age
NAMES OF THE PEOPLE YUO LIVE WITH WHO ARE UNDER 18 YEARS OLD
____________________________________________________________________________________.
5. I am responsible for the financial support of the following people who live in my household
NAMES OF THE PEOPLE YOU LIVE WITH THAT YOU ALSO FINANCIALLY SUPPORT
____________________________________________________________________________________.
6. THE COMBINED, MONTHLY
The combined income of all persons I am responsible for supporting is $_________________per
INCOME OF ALL THE
month (total from below). PEOPL YOU SUPPORT
YOUR HOURLY Income Received Each Month (before taxes)

PAY
Wages ($_____________ per hour xNUMBER OF HOURS$
_________
YOU WORK
hours per month) EACH MONTH
TOTAL MONTHLY WORK INCOME
Unemployment Compensation $ TOTAL MONTHLY UNEMPLOYMENT
AFDC/TANF Benefits TOTAL MONTHLY AFDC/TANF BENEFITS
$________________
SSI/SSD Benefits $ TOTAL MONTHLY SSI/SSD BENEFITS
Child Support $ TOTAL MONTHLY CHILD SUPPORT YOU GET
Other (please describe) $ ANY OTHER INCOME YOU GET
EACH MONTH
Total Income TOTAL OF THE ABOVE INCOME

$__________________
7. AMOUNT IN BANK in the bank.

We have $___________________
8. TOTAL MONTHLY per month. (Total from below).
Our expenses total $___________________
EXPENSES
CCA-GF-0420-3006
Monthly Expenses
Housing (Rent, Contract, or Mortgage) $ MONTHLY COST OF HOUSING
Utilities (Gas, Elective, Water, Phone, etc.) $
MONTHLY COST OF UTILITIES
Food $
MONTHLY COST OF FOOD
Child Care $
MONTHLY COST OF CHILD CARE
Medical Bills $ MONTHLY COST OF MEDICAL BILLS
Transportation $
MONTHLY COST OF TRANSPORTATION
Insurance (Car, Medical, and/or Property) $
MONTHLY COST OF INSURANCE
Child Support $ MONTHLY COST OF CHILD SUPPORT
Other (please describe) $ OTHER MONTHLY EXPENSES
Total Expenses $ TOTAL OF THE ABOVE EXPENSES
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.
There is no other party to serve.
I affirm under penalties for perjury that the foregoing representations and
statements are true.
DATE
______________________ SIGN HERE AFTER YOU PRINT THIS FORM
______________________________
Date Signature
YOUR PRINTED NAME

______________________________
Printed Name

CCA-GF-0420-3006
STATE OF INDIANA IN THE __________________ ______________ COURT
COUNTY OF _________________ CAUSE NO. ________________________________
__________________________ FOR THE SECTION ABOVE THE DOTTED LINE, LOOK AT

Petitioner THE FIRST FORM YOU FILLED OUT AND COPY THE
INFORMATION HERE.
v.
__________________________
Respondent
----------------------------------------------------------------------------------------------------------------------------------
ORDER ON FEE WAIVER

The Petitioner, self represented, has filed a Verified Motion For Fee Waiver which the Court
has read and finds should be granted.
IT IS THEREFORE ORDERED that Petitioner may file this case:

☐ Without the pre-payment of any filing fees, costs, security, bond or other expenses; or
LEAVE BLANK
☐ Upon the prepayment of $ ___________ which is a portion of the filing fee set by statute. Such
sum must be paid by the Petitioner to the Clerk within the next twenty (20) days.
The Court will determine whether any or additional costs are to be paid at a preliminary or
final hearing in this case.
__________________________________ _________________________________
Date Judicial Officer
Distribution:
YOUR NAME
_____________________________________
YOUR ADDRESS
_____________________________________
_____________________________________
_____________________________________

CCA-GF-0420-3007

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SELECT THE COURT TYPE

IF YOU KNOW IT. IF NOT,

STATE OF INDIANA IN THE COUNTY NAME

IN RE THE MATTER OF:

APPEARANCE BY UNREPRESENTED PERSON

Address: YOUR ADDRESS

SELECT THIS BOX

Caption and case number of related cases:

Page 1 of 2 Approved by the Coalition for Court Access

Caption: Case No.:

Additional information as required by local rule:

SIGN HERE AFTER YOU PRINT THIS FORM

Page 2 of 2 Approved by the Coalition for Court Access

COUNTY OF _________________ CAUSE NO. ________________________________

IN RE THE MATTER OF:

__________________________ FOR THE SECTION ABOVE THE DOTTED LINE, LOOK AT

YOUR HOURLY Income Received Each Month (before taxes)

Total Income TOTAL OF THE ABOVE INCOME

7. AMOUNT IN BANK in the bank.

Other (please describe) $ OTHER MONTHLY EXPENSES

Total Expenses $ TOTAL OF THE ABOVE EXPENSES

There is no other party to serve.

YOUR PRINTED NAME

Page 2 of 2 Approved by the Coalition for Court Access

COUNTY OF _________________ CAUSE NO. ________________________________

IN RE THE MATTER OF:

__________________________ FOR THE SECTION ABOVE THE DOTTED LINE, LOOK AT

ORDER ON FEE WAIVER

IT IS THEREFORE ORDERED that Petitioner may file this case:

Page 1 of 1 Approved by the Coalition for Court Access

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COUNTY OF _ CAUSE NO. ________________

COUNTY OF _ CAUSE NO. ________________