SOUTHERN JUDICIAL CIRCUIT
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
(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
(8) Other assets or property
(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
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 .
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
Mail or Fax completed
Attn: LISA SUTTON
313 West Dame Avenue, Suite C
Homerville, Georgia 31634
Phone: (912) 487-3003
Fax: (888) 613-1752