Here is the text we could read:
_____________________________
(Name)
_____________________________
(Address)
_____________________________
(City)
_____________________________
(Telephone)
Court Decision
_________ Date of approval
_________ Date of denial
____________________
(Initials of judge or clerk)
In the Utah Court of Appeals / Utah Supreme Court (circle one)
450 S State St.
Salt Lake City, UT 84111
_________________________, ( name)
Appellant / Appellee (circle one)
AFFIDAVIT AND APPLICATION
FOR WAIVER OF COURT FEES
vs.
______________________________, ( name)
Appellant / Appellee (circle one)
Appellate Case No. __________________
Case No. ____________________
Judge _______________________
I solemnly swear or affirm that the following is true: Due to my poverty, I am unable
to bear the expenses of the legal proceedings that I am about to begin, and I believe that I
am entitled to the relief sought in these proceedings.
To obtain a waiver of court fees, I am providing the following financial information:
NOTE: If Section1 below applies and is completed, then you do not need to complete Section 2. Section 2 must be
completed if Section 1 does not apply.
SECTION 1:
9999 I receive public assistance under Temporary Assistance to Needy Families (TANF),
Supplemental Security Income (SSI), Medicaid, or General Assistance (GA).
9 I am being represented in this action by Utah Legal Services, or by a volunteer attorney
designated by Utah Legal Services. I qualified for such representation because my income at the
time my case was accepted did not exceed 125% of federal poverty guidelines.
9 I am being represented in this action by Legal Aid Society of Salt Lake. I qualified for such
representation because my income at the time my case was accepted did not exceed 150% of
federal poverty guidelines.
Rev. May 12, 2009
Page 1
SECTION 2: Answer all the following questions only if Section I above does not apply.
Income:
I was born on:
If I am applying for my child, my child’s name is:
If I am applying for my child, my child’s date of
birth is:
9 I have the following job(s). My employer’s name and
address is:
Monthly pay before
deductions:
Monthly pay after
deductions:
$ _____________
$ _____________
Source of income
Source of income
(If you do not have a job, write “None” in this space.)
9 I have income from sources other than employment.
Include such sources as rental income, money or other
support from non-household family members, etc.)
9 I receive this much per month from government
programs. (Include such sources as social security
benefits, worker’s compensation, veterans non-
educational benefits, housing, food, other living
allowances, etc.)
9 I share a household with other adults, some of whom
have jobs and share the cost of household expenses. The
names and my relationship to these household members are
listed in this box:
Name: ___________________ Relation: ____________
Monthly pay before
deductions of other adults
in household:
$ ______________
$ _____________
Name: ___________________ Relation ____________
9 I receive this much alimony per month:
$ ______________
$ _____________
$ _____________
Assets
9 I have this much money in cash, in the bank, in stocks or bonds, or in other available
sources:
9 Other people or organizations owe me this much money:
9 If Applicant is a prisoner, how much is held in Applicant’s trust account?
(Certificate Regarding Inmate Account must be filed.)
Monthly income,
non-wage
$ _____________
Monthly income
from government
programs
$ _____________
Monthly pay after
deduction of other
adults in household:
$_____________
$_____________
$_____________
Rev. May 12, 2009
Page 2
9 I own or am buying a home, land, or other real property, and vehicles or other personal property as
listed below
.
Balance owed
Value
Property (home, land, vehicles, etc.) and
location
Home
Land and other real property
Cars, trucks, or other vehicles
Other personal property
Debt
9 I owe the following debts:
To whom owed
Amount
To whom owed
$_______
$_______
$_______
Expenses
9 In an average month, I spend money for the following items:
Food
Clothing
Gas
Water
Cost of housing
Telephone
Transportation
Electricity
Uninsured
medical expenses
Health insurance
Amount
$ ________
$ _________
$ _________
$ _________
$ _________
Amount
$________
$________
$________
$________
$________
Child support
Child care
Education expense
for children
Other (list)
Other (list)
Rev. May 12, 2009
$___________
$___________
$___________
$___________
Amount
$______
$______
$______
Amount
$_______
$_______
$_______
$_______
$_______
Page 3
9 The following people depend on me for support:
Name
Age
Relationship
Name
Age
Relationship
Lives in
household
with me:
Yes or No?
9 The following facts also indicate that I am unable to pay court fees and costs:
9
9
9
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Being sworn, I state that I have read this Affidavit and Application for Waiver of Court Fees, and
the statements in it are true and correct to the best of my knowledge. I realize that an
intentionally false statement could subject me to prosecution for perjury.
DATED: __________________________
_____________________________
Appellant
NOTARY CLAUSE
________________________________, Appellant, is personally known to me or presented
satisfactory proof of identity to me. After being sworn and while under oath, Appellant stated
that he or she was acting voluntarily, had read and understood the preceding document, and that
the contents were true. Appellant then signed the document in my presence.
Signed on _________________, 20____.
X______________________________________
Notary Public / Court Clerk
(Notary Seal)
Rev. May 12, 2009
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