Free Motion for Waiver of Prepayment of Court Fees and Costs - District of Columbia

Form 7a. Motion for Waiver of Prepayment of Court Fees and Costs. DISTRICT OF COLUMBIA COURT OF APPEALS

__________________________ , Appellant v. ___________________________, Appellee.

Appeal No. _____________

MOTION FOR WAIVER OF PREPAYMENT OF COURT FEES AND COSTS (IN FORMA PAUPERIS) 1 I am not able to pay any of the court fees and costs I am able to pay only the following court fees and costs (specify): ________________________________________________________________________ 2 My current street or mailing address is: ________________________________________________________________________ 3 My occupation, employer, and employer's address are (specify): ________________________________________________________________________ 4 My spouse's occupation, employer, and employer's address are (specify): ________________________________________________________________________ 5 No, I am not receiving financial assistance. Yes, I am receiving financial assistance under one or more of the following programs: SSI (Social Security Supplemental Income) General Assistance for Children AFDC (Aide to Families with Dependent Children) Medical Assistance If you checked Yes on box 5, you must attach documents to verify receipt of the benefits; you may then skip item 6 and sign at the bottom of this form. 6. My income and available assets are not enough to pay for the common necessaries of life for me and the people in my family whom I support, and also to pay court fees and costs. [If you check this box, you must complete the attached Financial Statement, Form 7b.] Warning: You must immediately tell the court if you become able to pay court fees or costs during this action. I declare under penalty of perjury that the information on this form and all attachments is true and correct: Date: ___________________________ ________________________________ (Type or print name) ________________________________ (Signature)