City, State, Zip 

 
Name 

 
Address 

 
Phone 

 
Email  

This is a private record 

 
 
 
 
 
 
 
Check your email. You will receive information and 
documents at this email address.  
 

I am   [  ]  Plaintiff/Petitioner 

[  ]  Defendant/Respondent 

[  ]  Plaintiff/Petitioner’s Attorney  [  ]  Defendant/Respondent’s Attorney  (Utah Bar #:__________) 
[  ]  Plaintiff/Petitioner’s Licensed Paralegal Practitioner 
[  ]  Defendant/Respondent’s Licensed Paralegal Practitioner   

(Utah Bar #:__________) 

In the  [  ] District  [  ] Justice  Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

_____________________________________ 
Plaintiff/Petitioner 

v. 

_____________________________________ 
Defendant/Respondent 

Motion to Waive Fees  
(Utah Code 78A-2-302 and Code of Judicial 
Administration Rule 4-508)  

_______________________________ 
Case Number 

_______________________________ 
Judge 

_______________________________ 
Commissioner (domestic cases) 

1. 

I cannot pay the court fees in this case. I believe I qualify for a waiver. I ask the 
court to waive the following fees: (Choose all that apply. If you need help, ask court staff.) 

[  ]  Filing fee (Refer to Cover Sheet): 
Amount: $ ____________  
[  ]  Divorce classes: education ($35) 

& orientation ($30.00) 
[  ]  Office of Vital Records fee 
(Adoption Certificate or Divorce 
Certificate - $8.00)  

[  ]  Fee to have papers served in 

Utah   

[  ]  OCAP fee ($20.00) 
[  ]  Appeal fee 

[  ]  $240 Filing   
[  ]  $10 Small claims appeal (Justice 

Court)  

[  ]  Other _____________________ 

1305GEJ Approved June 24, 2019 / 
Revised January 20, 2023 
 

Motion to Waive Fees 

Page 1 of 2 

I qualify for a fee waiver because: (Choose all that apply.) 

a. [  ]  I receive: (Choose all that apply.) 

[  ] Food Stamps (SNAP) 

[  ] SSI 

[  ] Medicaid 

 

 

[  ] FEP or TANF

b. [  ]  I receive legal services from: 

[  ] a nonprofit provider: (name of provider) ____________________________  

 

[  ] a pro bono attorney through the Utah State Bar.  

c. [  ]  the gross monthly income for my household (before deductions for taxes) 

is equal to or is less than the amount listed below: (Choose one.) 

Household 
size 

Household 
income 

Household 
size 

Household 
income 

Household 
size 

Household 
income 

[  ] 1 

[  ] 2 

$1,822.50 

$2,465.00 

[  ] 3 

[  ] 4 

$3,107.50 

$3,750.00 

[  ] 5 

[  ] 6 

$4,392.50 

$5,035.00 

[  ] My household is larger than 6. My household size is ____ and our household income is 

$__________. (For each additional household member over six, add $642.50) 

d. [  ]  I don’t qualify under options a-c above. But I don’t have enough money to 
pay the court fees and provide myself or my family with food, shelter, 
clothing, or other necessities. (If you choose this option you must fill out the 
Extra Information for Fee Waiver form). 

3. 

[  ]  The amount of money held in my prisoner trust account is: $_____________.  

I do solemnly swear or affirm that due to my poverty I am unable to bear the expenses 
of the action or legal proceedings which I am about to commence or the appeal which I 
am about to take, and that I believe I am entitled to the relief sought by the action, legal 
proceedings, or appeal. 

Plaintiff/Petitioner or Defendant/Respondent  

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

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

 

 

 

 

 

  

. 

    2

 

 

Attorney or Licensed Paralegal Practitioner of record (if applicable) 

 
Date 

 
Date 

Signature ► 

Printed Name 

Signature ► 

Printed Name 

 

 

 

 

1305GEJ Approved June 24, 2019 / 
Revised January 20, 2023 
 

Motion to Waive Fees 

Page 2 of 2 

xtra Information for Fee Waiver 

            Case Number ___________________ 

(Do you need to complete this form? Only if you are not receiving public assistance, legal services from a 
nonprofit provider or a pro-bono attorney through the Utah State Bar, or do not meet the federal poverty 
guidelines.)  

Employment  

[  ] 

I am employed as (Choose all that apply): 

[  ]  an hourly employee (Form W-2) 

[  ]  a salaried employee (Form W-2) 

[  ]  self-employed (Form 1099, Form K-1, Schedule C, etc.) 

[  ]  other (Explain): _____________________________________________ 

Name of employer 

Employer's address and 
phone number 

Job title 

Hourly 
rate or 
annual 
salary 

Hours per 
week 
(If hourly) 

 

 

 

 

 

 

$ 

$ 

$ 

 

 

 

 

 
 

 
 

 
 

 

  E

. 

  1

2. 

Dependents (Count spouse, children or other dependents in your household. If none, write 0.) 

The following people depend on me for support. 

[  ] 

I am unemployed because:  

     

Number of adults 

Number of children under 18 

 

 

1301GEJ Approved June 24, 2019 / 
Revised September 13, 2022 
 

Motion to Waive Fees  

Page 1 of 8 

3. 

Gross Monthly Income  

[  ] 

I have the following monthly income before tax deductions:  
(Print your pre-tax income in the boxes below. For income that changes from month to 
month, calculate the annual total and divide by 12 months to list a monthly average.) 

Source of income 

Monthly amount 

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

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

Rental income 

Business income 

Interest 

Dividends 

Worker’s compensation 

Private disability insurance  

Social Security Disability Income (SSDI) 

Supplemental Security Income (SSI) 

Social Security (Other than SSDI or SSI) 

Unemployment benefits 

Veteran’s benefits 

Alimony 

Child support 

Payments from civil litigation 

Victim restitution 

Public assistance (Including AFDC, FEP, TANF, welfare, etc.) 

Financial support from household members 

Financial support from non-household members 

Education benefits (Including grants, loans, cash scholarships, etc.) 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Total gross monthly income  $ 

Motion to Waive Fees  

Page 2 of 8 

  ]  I have no income because: 

  [

1301GEJ Approved June 24, 2019 / 
Revised September 13, 2022 
 

Trust income 

Annuity income 

Other (Describe) 

Other (Describe) 

4. 

Monthly Tax Deductions   

[  ] 

I have no monthly tax deductions because I have no income. 

[  ] 

I have the following monthly tax deductions. 

Type of tax deduction 

Amount 

Federal income tax 

State income tax 

Municipal income tax 

FICA 

Medicare 

$ 

$ 

$ 

$ 

$ 

Total monthly tax deductions  $ 

5. 

After Tax Income   

[  ]  My monthly income is: 

$ 

- $ 

 
 
= $ 

 

 

 

  Gross monthly income from section 5 

  Minus monthly tax deductions from section 6 

 

 

 

  Equals after-tax monthly income 

[  ]    I have no income. 

6. 

Monthly Expenses  (Include amounts you pay for yourself and any spouse, children or other 
dependents in your household.) 

Monthly expense 

Current 
Amount 

Rent or mortgage 

Real estate taxes (if not included in mortgage) 

Real estate insurance (if not included in mortgage) 

Real estate maintenance 

Food and household supplies 

Clothing 

$ 

$ 

$ 

$ 

$ 

$ 

1301GEJ Approved June 24, 2019 / 
Revised September 13, 2022 
 

Motion to Waive Fees  

Page 3 of 8 

       

Monthly expense 

Current 
Amount 

Other transportation costs  (public transportation, parking, etc.) 

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

Automobile payments 

Automobile insurance 

Automobile fuel 

Automobile maintenance 

Telephone 

Paid television, cable, satellite 

Internet 

Credit card payments 

Loans and other debt payments 

Alimony 

Child support 

Child care 

Extracurricular activities for children 

Education (children) 

Education (self) 

Health care insurance  

Other insurance (describe) 

Entertainment 

Laundry and dry cleaning 

Donations 

Gifts 

Union and other dues 

Other (describe) 

Other (describe) 

Health care expenses  (excluding insurance listed above) 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Garnishment or income withholding order 

Retirement deposits (including pensions, 401(k), IRA, etc.) 

Total monthly expenses  $ 

7. 

Business Interests  (Add additional sheets if needed.)  

[  ] 

I have no business interests. 

1301GEJ Approved June 24, 2019 / 
Revised September 13, 2022 
 

Motion to Waive Fees  

Page 4 of 8 

[  ] 

I have the following business interests. 

Current value of the business 

Percent owned by 

_____% Petitioner            _____% Respondent 

Current value of the business 

Percent owned by 

_____% Petitioner            _____% Respondent 

8.  

Financial Assets  (Add additional sheets if needed.) 

[  ] 

I have no financial assets. 

[  ] 

I have the following financial assets. 

Name & address of 
institution 

Names on account 

Current 
balance 

Business name 

Address & phone 

Nature of business 

Business name 

Address & phone 

Nature of business 

$ 

 

$ 

Asset 

Bank or credit union  
Account number: 
_______________ 
Date opened: 
_______________ 
Type: 
[  ]  checking 
[  ]  savings 
[  ]  other  

Bank or credit union  
Account number: 
_______________ 
Date opened: 
_______________ 
Type: 
[  ]  checking 
[  ]  savings 
[  ]  other  

 

 

 

 

 

 

 

 

 

 

$ 

$ 

1301GEJ Approved June 24, 2019 / 
Revised September 13, 2022 
 

Motion to Waive Fees  

Page 5 of 8 

Name & address of 
institution 

Names on account 

Current 
balance 

Asset 

Stocks, bonds, 
securities, money 
market account  
Account number: 
_______________ 
Date opened: 
_______________ 

Retirement account 
Account number: 
_______________ 
Date opened: 
_______________ 

Profit sharing plan 
Account number: 
_______________ 
Date opened: 
_______________ 

Annuity 
Account number: 
_______________ 
Date opened: 
_______________ 

Life insurance 
Account number: 
_______________ 
Date opened: 
_______________ 

Money owed to me 
Date of loan: 
_______________ 

Cash 

Other (describe) 

Other (describe) 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

9. 

Real Estate  (Add additional sheets if needed.) 

[  ] 

I have no real estate. 

[  ] 

I have the following real estate. 

Home 

1301GEJ Approved June 24, 2019 / 
Revised September 13, 2022 
 

Motion to Waive Fees  

Page 6 of 8 

 

 

 
 

 

 

 

 
 

 

$ 

$ 

$ 

$ 

$ 

$ 

 

$ 

  $ 
 

  $ 
 

 

$ 

  $ 
 

  $ 
 

  Name(s) on title 

  Original cost 

  Current value 

First mortgage or lien holder (name & address) 

Amount owed 

Monthly payments 

 
Second mortgage or lien holder (name & address) 

Amount owed 

Monthly payments 

  Name(s) on title 

  Original cost 

  Current value 

First mortgage or lien holder (name & address) 

Amount owed 

Monthly payments 

 
Second mortgage or lien holder (name & address) 

Amount owed 

Monthly payments 

10.  Personal Property  (Such as vehicles, boats, trailers, major equipment, furniture, jewelry, 

and collectibles. Add additional sheets if needed.) 

[  ] 

I have no personal property. 

[  ] 

I have the following personal property. 

Property description 
(if automobile, include 
year, make, and model) 

Debt owed to  
(name and address) 

Names on title  
(if applicable) 

Amount 
owed 

Minimum 
monthly 
payments 

  

 

  

  

  

 

 

 

 

 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

11.  Debts Owed  (Do not include amounts you owe on property reported in the Real Estate or 

Personal Property sections. Add additional sheets if needed.) 

[  ] 

I do not owe any debts. 

[  ] 

I owe the following debts. 

1301GEJ Approved June 24, 2019 / 
Revised September 13, 2022 
 

Motion to Waive Fees  

Page 7 of 8 

 

  

 

  

 

 

 

 

 

 

 

 
Date acquired 
 

ddress 

  A

ther real estate 

ddress 

 
Date acquired 
 

  O

  A

Type of debt 
(such as credit card, 
cash loan, or installment 
payment) 

Debt owed to 
(name and address and 
phone number) 

Names on debt 

Amount 
owed 

Minimum 
monthly 
payments 

 

 

 

 

 

 

 

 

 

 

 

 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

12.  Other 

[  ]  The following facts also show why I cannot pay these court fees. 

laintiff/Petitioner or Defendant/Respondent  

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

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

Attorney or Licensed Paralegal Practitioner of record (if applicable) 

Signature ► 

Printed Name 

Signature ► 

Printed Name 

 

 

 

 

1301GEJ Approved June 24, 2019 / 
Revised September 13, 2022 
 

Motion to Waive Fees  

Page 8 of 8 

 

 

 

 

 

 

       

    P

 
Date 

 
Date