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Here is the text we could read:

Plaintiff/Petitioner’s name, address, and telephone no.

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

Instructions: Complete this form and file it with the court. 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 $
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.

every
.

Week/Two weeks/Month/Year

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

STATE OF MICHIGANJUDICIAL DISTRICTJUDICIAL CIRCUITCOUNTY PROBATEFEE WAIVER REQUESTCASE NO. and JUDGECourt address Court telephone no. JIS CODE: OSFApproved, SCAOForm MC 20, Rev. 10/19MCR 2.002Page 1 of 2Distribute form to: Court Applicant Other parties Friend of the court (when applicable)Fee Waiver Request
Page 2 of 2

(10/19)

Case No.

1. Payment of filing fees is waived.

CLERK WAIVER

Signature of court clerk and date

ORDER

IT IS ORDERED:

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

1. Payment of filing fees is waived because:

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.

a. Your gross household income is above 125% of the federal poverty guidelines and payment of

2. The fee waiver request is denied because:

the fees would not constitute a financial hardship for you.

b. Other:

Judge/Magistrate (when authorized) signature and date

NOTICE

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)

MC 20, Fee Waiver Request

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.courts.michigan.gov/general-use (2023-03)
Page(s): 2
Fields(s): 42
Average fields per page: 21
Reading Level: Grade 8
LIST Grouping(s): Unknown

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

plaintiff_petitioners_address was PlaintiffPetitioners name address and telephone no (0.70 conf)
defendant_name_address was DefendantRespondents name address and telephone no (0.45 conf)
plaintiff_petitioners_attorney was PlaintiffPetitioners attorney bar no address and telephone no (0.54 conf)
defendant_attorney_address was DefendantRespondents attorney bar no address and telephone no (0.48 conf)
matter was In the matter of (0.33 conf)
receive_public_assistance was 1 I receive the following types of public assistance because of indigence (0.36 conf)
program_assistance_law was 2 I am represented by a legal services program or I receive assistance from a law school clinic because (0.45 conf)
unable_pay_fees_check_item was 3 I am unable to pay the fees and I did not check item 1 or 2 above (0.40 conf)
food_assistance_program_state_michigan was Food Assistance Program through the State of Michigan also known as FAP or SNAP (0.46 conf)
medicaid_including_healthy_michigan_chi_p_eso was Medicaid including Healthy Michigan CHIP and ESO (0.41 conf)
family_independence_program_state_michigan_also_known_fi_p_tanf was Family Independence Program through the State of Michigan also known as FIP or TANF (0.40 conf)
women_infants_children_benefits was Women Infants and Children benefits WIC (0.37 conf)
income_federal_ssi was Supplemental Security Income through the federal government SSI (0.56 conf)
meanstested_public_assistance was Other meanstested public assistance (0.44 conf)
public_assistance_case was My public assistance case numbers if any is (0.41 conf)
write_none_case_number_ssn was Write none if no case number Do not write your SSN (0.44 conf)
undefined__1 was undefined (0.38 conf)
number_people_household was The number of people in my household is (0.38 conf)
week_two_weeks_month_year was WeekTwo weeksMonthYear (0.32 conf)
undefined__2 was undefined_2 (0.39 conf)
assets_accounts_space_separate was List assets and their worth such as bank accounts If you need more space attach a separate sheet (0.46 conf)
signature_date was Date (1.00 conf)
text__1 was Text1 (0.35 conf)
text__2 was Text2 (0.35 conf)
text__3 was Text3 (0.35 conf)
judge was Judge (0.39 conf)
text__4 was Text5 (0.35 conf)
text__5 was Text6 (0.35 conf)
text__6 was Text7 (0.35 conf)
text__7 was Text8 (0.35 conf)
text__8 was Text9 (0.35 conf)
payment_filing_fees_waived was 1 Payment of filing fees is waived because (0.44 conf)
fee_waiver_request_denied was 2 The fee waiver request is denied because (0.43 conf)
household_income_federal__1 was a Your gross household income is under 125 of the federal poverty guidelines (0.48 conf)
household_income_federal__2 was b Your gross household income is above 125 of the federal poverty guidelines but payment of (0.41 conf)
c was c Other (0.35 conf)
household_income_federal__3 was a Your gross household income is above 125 of the federal poverty guidelines and payment of (0.40 conf)
b was b Other (0.35 conf)
issue_date_completed_clerk was Issue date completed by clerk (0.38 conf)
text__9 was Text10 (0.35 conf)
text__10 was Text11 (0.35 conf)
text__11 was Text12 (0.35 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

MC 20, Fee Waiver Request

About This Form:

Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02