DETERMINATION REGARDING FEES AND COSTS

_________________
Court

________________________________________
Case Name and Number

Name of Applicant __________________________________________________________________________

Address

______________________________________________________________________________
(Street and number)

(City of Town)

(State and Zip)

FORTHWITH DETERMINATION BY CLERK (Register,  Recorder)

9 ALLOWED FORTHWITH.  The applicant's affidavit appears regular and complete on its face, indicates
that the applicant is indigent, and requests waiver, substitution or payment by the Commonwealth of normal
fees and costs only.  Pursuant to G. L. c. 261, § 27C(2), the application is therefore ALLOWED forthwith
without hearing, and the normal fees and costs indicated in the application are:

9 waived in full

9to be paid by the Commonwealth in the amount of $                 

9 REFERRED TO A JUDGE.  The applicant's affidavit does not satisfy all the conditions of § 27C(2), and is

therefore referred to a judge pursuant to § 27C(3), because:

9 The affidavit is not regular and complete on its face.

9 The affidavit does not indicate that the applicant is indigent within the meaning of § 27A.

9 The affidavit requests waiver, substitution or payment by the Commonwealth of extra fees and costs.

Comments:

Describe fees and costs waived:

Date

Clerk-Magistrate/ Assistant Clerk (register, recorder/assistant)

__________________________________________________________________________________________

X

DETERMINATION BY JUDGE 9 after hearing 9 without hearing

NORMAL FEES AND COSTS

9 The application is ALLOWED with respect to the normal fees and costs indicated in the application, and
they are ordered:

9 waived in full. 9 to be paid by the Commonwealth in the amount of $               .

9 waived in part.  I find that it is within the applicant's limited financial means to pay a reduced amount of
 $                    .

9 to be avoided by the provision of                                                                                to the applicant,
pursuant to § 27F, as an alternative which is available at lower or no cost, is substantially equivalent and
does not materially impair the rights of any party.

9 The application is DENIED with respect to the normal fees and costs indicated in the application, because I

9 The applicant is not indigent within the meaning of § 27A.

find that:

9 Other:

Describe normal fees and costs waived:

EXTRA FEES AND COSTS

9 The application is ALLOWED with respect to the extra fees and costs indicated in the application, and they
are ordered:

9   waived in full.

9to be paid by the Commonwealth in the amount of $                  .

9 waived in part.  I find that it is within the applicant's limited financial means to pay a reduced amount of 
$                     .

9 to be avoided by the provision of                                                                                to the applicant, pursuant
to § 27F, as an alternative which is available at lower or no cost, is substantially equivalent and does not
materially impair the rights of any party.

9 The application is DENIED with respect to the extra fees and costs indicated in the application, because I

9 The applicant is not indigent within the meaning of § 27A.

9 The document, service or object is not reasonably necessary to assure the applicant as effective a
prosecution, defense or appeal as if the applicant were financially able to pay.

find that:

9 Other:

Date     

Describe extra fees and costs waived:

Judge

X

The applicant may appeal denial of this application by filing a notice of appeal with the clerk (register,
recorder) of this court within 7 days from notice of denial.