SOUTHERN JUDICIAL CIRCUIT

 


CASE NAME:                                                                                                                                                                                                           


COUNTY:                                                                                          
CASE NUMBER:                                                                                            

NAME OF PARTY REQUESTING WAIVER:                                                                                                                                                             
 

THE UNDERSIGNED, BEING FIRST DULY SWORN ON OATH, DEPOSES AND SAYS:

 

I understand the following information that I am providing is true and intended to be relied upon by the Court Administrator of the Southern Judicial Circuit to determine my eligibility for the wavier of the $30.00 fee.

I. GENERAL INFORMATION

 

    (1) Name:                                                                                                                                                                

 

    (2) Address:                                                                                                                                                           

    (3) Social Security No.:                                                       (4) Birth Date:                                                                 

 

    (5) Number of Dependent Children:                       (6)             Divorced             Separated            Married             Single

 

II. INCOME AND ASSETS

 

    (1) Weekly income (Take-Home)                                                                                                                                   

 

    (2) Employer or other source of income (including government agency)                                                                             

 

    (3) If unemployed, name of last employer, and date of termination                                                                                    

 

    (4) Monthly or weekly income of spouse or dependents                                                                                                   

 

    (5) Employer or other source of spouse's income (including government agency)                                                                

 

    (6) Home or other real estate: Value                                                       Equity                                                              

 

    (7) Automobiles                                                                                                                                                           

 

    (8) Other assets or property                                                                                                                                          

 
    (9) Money: (a) Checking Accounts                                                           (b) At Home                                                    


                     (c) Savings Accounts                                                             (d) Safe Deposit Box                                       


III. EXPENSES AND DEBTS


    (1) Rent or Mortgage                                      (2) Food                                          (3) Utilities                                        

 

    (4) Transportation                                             (5) Installment Payments                                                                      

 

    (6) Medical and Dental                                        (7) Insurance, i.e., (Auto, Home)                                                          

 

    (8) Child Care, i.e., Day Care for Working Mothers                                                                                                          


    (9) Child Support                                                              (10) Alimony                                                                         




 

NAME OF CREDITOR - AMOUNT OWED                                          NAME OF CREDITOR - AMOUNT OWED

 

                                                                                                                                                                                     

  

                                                                                                                                                                                     

 

                                                                                                                                                                                

                                            

 
I declare under penalty of perjury that the foregoing is true and correct; I am aware that perjury is a felony punishable by a fine of not more than $1,000.00 or imprisonment for not less than one year, nor more than 10 years.


         READ, DATED AND SIGNED, this              day of                                                                    , 20           .



                                                                                                                                                                            

                                                                                   Party's Signature



Sworn to and subscribed before me,
 

this               day of                                                               , 20              .

 

                                                                                                        

Notary Public

 

The above and foregoing application read and considered, the above named Party IS/IS NOT entitled to a waiver of the fee. 

 

                   This                day of                                                                           , 20            .



                                                                                                                                                                                    

                                                                                           Tim C. Hendrick
                                                                                           Circuit Court Administrator

                                                                                           Southern Judicial Circuit



County:                                                                                               

File Name:                                                                                          

File No.:                                                                                              

Party Name:                                                                                        

 

 

 

Mail or Fax completed Application

Attn: LISA SUTTON
313 West Dame Avenue, Suite C

Homerville, Georgia 31634
Phone: (912) 487-3003
Fax: (888) 613-1752