Free TF-920 - Alaska

To Clerk: Do not issue summons until request is granted or filing fee is paid.
IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT _______________________ ) ) ) ) ) ) ) ) )

Plaintiff, vs.

CASE NO. REQUEST FOR EXEMPTION FROM PAYMENT OF FEES

Defendant.

I, , request exemption from payment of the fees listed in Administrative Rule 9(f)(1) due to my financial inability to pay. FINANCIAL STATEMENT Phone: Residence Address: Mailing Address: Present Employer: Employer's Address: Date of Birth:

(If not now employed, state last employer and date terminated) Employer's Phone:

1.

INCOME INFORMATION (after taxes, but before other deductions) a. Income during last 12 months: You Your Spouse Wages ......................................... Public Assistance ........................ Unemployment ............................ Other (Specify) TOTAL: b. Current monthly income from all sources: FAMILY MONTHLY EXPENSES: Food Rent Utilities Car payments Furniture & Equipment payments Child support or alimony Loans/Time payments TOTAL EXPENSES:

2.

Page 1 of 2 TF-920 (10/06)(cs) REQUEST FOR EXEMPTION FROM PAYMENT OF FEES

Adm. R. 9(f)(1) and 10 Civil R. 90.3

3.

FAMILY ASSETS ­ Present Value: Cash on hand or in bank Land, buildings or trailers Cars Snow machines, boats airplanes or other motor vehicles (except cars) Securities: stocks, bonds, notes Businesses Other Assets:

4.

FAMILY DEBTS: Mortgages Loans Charge cards Other (bills, etc.):

TOTAL DEBT:

TOTAL ASSETS: 5. DEPENDENTS: Name Age Relationship

I swear or affirm that this financial statement is true. I understand that if I give false information in the financial statement, I may be prosecuted for perjury.

Date Subscribed and sworn to or affirmed before me at on . (date) (SEAL)

Signature of Plaintiff/Defendant , Alaska

Notary Public/Judge/Court Clerk My Commission Expires:

ORDER It is ordered that the request for exemption from payment of fees is: GRANTED. Plaintiff/Defendant is exempted from payment of the fees specified in Administrative Rule 9(f)(1). DENIED. Any fees now due in this case must be paid before any further action is taken. If payment is not made within 30 days after notice of the order, the court may dismiss the action. Admin.Rule 10(d).

Date
I certify that on a copy of this order was sent to: Clerk:

Judge/Magistrate Type or Print Name
Adm. R. 9(f)(1) and 10 Civil R. 90.3

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