Name 
 
Address 
 
City, State, Zip 
 
Phone 
 
Email 

I am the 

 
 
 
 
 
 

 
 
 

[  ]  Petitioner 
[  ]  Respondent 
[  ]  Subject of the Proceedings 
[  ]  Attorney for the  [  ]  Petitioner   [  ]  Respondent and my Utah Bar number is _______ 

In the Juvenile Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

State of Utah, in the interest of 

Financial Statement Supporting 
Motion to Waive Fees 

_____________________________________ 
Last name, first name 

_______________________________ 
Case Number 

_____________________________________ 
Date of birth 

_______________________________ 
Judge 

A minor 
[  ] under [  ] over  18 years of age, and 
[  ] represented [  ] not represented. 

Instructions: Attach continuation pages, if needed to complete paragraphs that don’t have enough 
space. Write the paragraph number on the continuation page. 

I swear or affirm that: 

 
 

the following information is true and correct; and 
I have omitted nothing that is relevant to my financial status. 

Financial Statement Supporting Motion to Waive 
Fees  
 

     Approved Board of Juvenile Court Judges  April 17, 2013 
Revised March 18, 2019 

Page 1 of 6 

1. 

Employment Status. 

[  ]   

I am employed (including self-employment). 

[  ]   

I am unemployed. 

2. 

Monthly Income.  

[  ]  I have the following monthly income: 

Amount 

Source of Income 

Work (Including self employment, wages, salaries, commissions, bonuses, 
and tips) 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Rental Income 

Business Income 

Interest and Dividends 

Retirement Income (Including pensions, 401(k), IRA, etc.) 

Worker’s Compensation 

Social Security Disability (SSDI and SSI) 

Private Disability Insurance  

Social Security (Do not include SSDI or SSI) 

Unemployment Benefits 

Education Benefits 

Veteran’s Benefits 

Alimony 

Child Support 

Payments from Civil Litigation 

Victim Restitution 

Public Assistance (Including AFDC, welfare, etc.) 

Support from household members 

Support from non-household members 

Trust Income 

Annuity Income 

Other (Describe) 

Financial Statement Supporting Motion to Waive 
Fees  
 

     Approved Board of Juvenile Court Judges  April 17, 2013 
Revised March 18, 2019 

Page 2 of 6 

Amount 

Source of Income 

Total 

[  ]  I have no income because: 

3. 

Monthly Deductions.  

[  ]  I have the following deductions from my income: 

Amount 

Type of Deduction 

Federal Income Tax 

State Income Tax 

FICA 

Health Insurance Premiums 

Life Insurance Premiums 

Union and other dues 

Other (Describe) 
 

Total 

Garnishment or Income Withholding Order 

Retirement Deposits (Including pensions, 401(k), IRA, etc.) 

[  ]  I have no income. 

4. 

Net Monthly Income. My net monthly income is: 

Income (from (2)) minus Deductions (from (3)) 

5. 

Financial Assets. 

[  ]  I have the following financial assets: 

$ 

   

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Financial Statement Supporting Motion to Waive 
Fees  
 

     Approved Board of Juvenile Court Judges  April 17, 2013 
Revised March 18, 2019 

Page 3 of 6 

Holder 
(Name & Address) 

Co-owner 
(Name & Address) 
(If co-owner is not a party, 
use Non-public Information 
Form for Address) 

Current Value 

Asset 

Bank or Credit Union 
Account 
Last 4 digits of acct number: 
_________ 
Bank or Credit Union 
Account 
Last 4 digits of acct number: 
_________ 
Stocks, Bonds, 
Securities, Money Market 
Fund 
Last 4 digits of acct number: 
_________ 
Stocks, Bonds, 
Securities, Money Market 
Fund 
Last 4 digits of acct number: 
_________ 

Money Owed to You 

Cash 

Other (Describe) 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

6. 

Monthly Expenses. I am personally paying the following monthly expenses: 

Amount 

Monthly Expense 

Rent or mortgage 

Food and Household Supplies 

Clothing 

Transportation (Such as public transportation, automobile payments, 
insurance, gas, maintenance) 

Utilities (Such as electricity, gas, water, sewer, garbage) 

Telephone 

$ 

$ 

$ 

$ 

$ 

$ 

Financial Statement Supporting Motion to Waive 
Fees  
 

     Approved Board of Juvenile Court Judges  April 17, 2013 
Revised March 18, 2019 

Page 4 of 6 

Amount 

Monthly Expense 

Credit Card Payments 

Loans and Other Debt Payments 

Health Care Insurance  

Health Care Expenses (Excluding insurance listed above) 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

 

 

 

 

 

Alimony 

Child Support 

Child Care 

Education 

Business Expenses 

Real Property Taxes 

Real Property Insurance 

Real Property Maintenance 

Other Insurance (Describe) 

Entertainment 

Laundry and Dry Cleaning 

Donations 

Gifts 

Other (Describe) 

Total 

 

 

 

 

 

 

 

 

 

 

7. 

Dependents. The following people depend on me for support. 

Name 

Age  Relationship 

Financial Statement Supporting Motion to Waive 
Fees  
 

     Approved Board of Juvenile Court Judges  April 17, 2013 
Revised March 18, 2019 

Page 5 of 6 

8. 

Other. The following facts also show that I am unable to pay the expenses of 
these legal proceedings. 

 declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

Signature ► 

Printed Name 

 

 

   

    I

   

 
Date 

Financial Statement Supporting Motion to Waive 
Fees  
 

     Approved Board of Juvenile Court Judges  April 17, 2013 
Revised March 18, 2019 

Page 6 of 6