Public Assistance Services Program
Resume:
Plaintiff/Petitioner’s name, address, and telephone no.
v
Defendant/Respondent’s name, address, and telephone no. Plaintiff/Petitioner’s attorney, bar no., address, and telephone no. Defendant/Respondent’s attorney, bar no., address, and telephone no. In the matter of
STATE OF MICHIGAN
JUDICIAL DISTRICT
JUDICIAL CIRCUIT
COUNTY
FEE WAIVER REQUEST
CASE NO. and JUDGE
Court address Court telephone no.
JIS CODE: OSF
Approved, SCAO
Form MC 20, Rev. 9/23
MCR 2.002
Page 1 of 2
Distribute form to:
Court
Applicant
Other parties
Friend of the court (when applicable)
Instructions: Complete this form and file it with the court. If this request is filed by a prisoner, a certified statement of the prisoner’s trust account showing a current balance and a 12-month history of deposits and withdrawals must accompany this form. After you receive a decision on your request, you must serve your request and the decision on the other party(ies). I request a waiver of my filing fees for the following reason: (Check 1, 2, or 3) 1. I receive the following type(s) of public assistance because of indigence: Food Assistance Program through the State of Michigan (also known as FAP or SNAP) Medicaid (including Healthy Michigan, CHIP, and ESO) Family Independence Program through the State of Michigan (also known as FIP or TANF) Women, Infants, and Children benefits (WIC)
Supplemental Security Income through the federal government (SSI) Other means-tested public assistance:
My public assistance case number(s) (if any) is
Write “none” if no case number. Do not write your SSN.
.
2. I am represented by a legal services program or I receive assistance from a law school clinic because of indigence. The name of the legal services program or law school clinic is
.
3. I am unable to pay the fees and I did not check item 1 or 2 above. My gross household income is $
every
Week/Two weeks/Month/Year
.
The number of people in my household is
.
My source of income is
.
List assets and their worth, such as bank accounts. If you need more space, attach a separate sheet. List obligations and how much you pay, such as rent or other debts. If you need more space, attach a separate sheet. I declare under the penalties of perjury that this request has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date
Signature
15-160764-DP FILED IN MY OFFICE Cathy M. Garrett WAYNE COUNTY CLERK 6/4/2024 2:24 PM Stacey Stallworth 15-160764-dp
Terrance Ward
35 Baldwin Ave E
Battle Creek, MI 49037
Anjel Jackson Smith
1476 Deacon St
Detroit, MI 48217
06/04/2024 Terrance Ward
Fee Waiver Request (9/23)
Page 2 of 2
Case No.
1. Payment of filing fees is waived.
Signature of court clerk and date
IT IS ORDERED:
1. Payment of filing fees is waived because:
a. Your gross household income is under 125% of the federal poverty guidelines. b. Your gross household income is above 125% of the federal poverty guidelines, but payment of the fees would constitute a financial hardship for you. c. Other:
If you become able to pay the fees before this case is resolved, you must notify the court. 2. The fee waiver request is denied because:
a. Your gross household income is above 125% of the federal poverty guidelines and payment of the fees would not constitute a financial hardship for you. b. Other:
Judge/Magistrate (when authorized) signature and date IF YOUR REQUEST WAS DENIED: To continue your case and preserve your filing date, you have 14 days from the issue date below to pay the filing fees or request a review. To request a review, fill out a Request for Review of Denied Fee Waiver
(form MC 114) and file it with the court.
Issue date (completed by clerk)
CLERK WAIVER
ORDER
NOTICE
15-160764-DP FILED IN MY OFFICE Cathy M. Garrett WAYNE COUNTY CLERK 6/4/2024 2:24 PM Stacey Stallworth x
x
/s/ Stacey Stallworth 06/04/2024
/s/ Hon. Patricia P Fresard 06/04/2024
15-160764-dp
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