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Here is the text we could read:

 

 
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 

Motion and Statement 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. 

[  ]  Filing Fee 

[  ]  Service Fee 

[  ]  Future fees for writs 

1. 

I move to waive the following court fees: (Choose all that apply.) 

[  ]  Other (Describe) ______________________________________________ 

[  ]  Other (Describe) ______________________________________________ 

 

 

Motion and Statement to Waive Fees  

     Approved Board of Juvenile Court Judges  April 17, 2013 
Revised March 19, 2019 

Page 1 of 2 

I swear or affirm that: 

2. 

Due to my poverty, I am unable to bear the expenses of these legal proceedings, 
and I believe that I am entitled to the relief sought. 

3. 

[  ]  This is a juvenile court case. I have attached the financial declaration 

required for such cases. 

4. 

[  ] 

I receive public assistance under: (check all that apply and attach the financial 
statement used to qualify for the program) 

[  ]  Temporary Assistance to Needy Families (TANF); or 
[  ]  Supplemental Security Income (SSI); or 
[  ]  Medicaid; or 
[  ]  General Assistance (GA); or 
[  ]  Other _________________________________________ (describe); 
and 

[  ]  The attached financial information is true and correct. 

5. 

[  ] 

I am being represented in this action by: (check all that apply and attach the 
financial statement used to qualify for representation) 

[  ]  A court-appointed attorney; 
and 
[  ]  The attached financial information is true and correct. 

6. 

[  ] 

I have attached a Financial Statement Supporting Motion to Waive Fees. 

 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 

 

 

Motion and Statement to Waive Fees  

     Approved Board of Juvenile Court Judges  April 17, 2013 
Revised March 19, 2019 

Page 2 of 2 

    I

   

 

 
Date

Motion and Statement to Waive Fees

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah 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 legacy.utcourts.gov (2023-03)
Page(s): 2
Fields(s): 103
Average fields per page: 51
Reading Level: Grade 8
LIST Grouping(s): GO-00-00-00-00.

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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.

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

Motion and Statement to Waive Fees

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