Free PC-184 - Connecticut

REQUEST/ORDER WAIVER OF FEES - PETITIONER PC-184 REV. 10/07

STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] DISTRICT NO. RESPONDENT

DO NOT RECORD

TO: COURT OF PROBATE, DISTRICT OF PETITIONER

APPLICANT IN PROCEEDINGS FOR:

The petitioner represents that the GROSS MONTHLY household income from employment is: $ 0.00 NET MONTHLY INCOME shown below after deductions for: State withholding FICA and Medicare $ Federal withholding $ $ 0.00 0.00 Union dues $
0.00

,leaving the
0.00
0.00

Wage executions

$

0.00

Other

$

(Please attach a copy of paycheck stub(s) for each employed household member, and explain "Other" deductions on reverse side.) NET MONTHLY INCOME FROM EMPLOYMENT: $ The petitioner further represents that other household income (broken down monthly) is as follows: Welfare Social Security Unemployment Compensation $ $ $
0.00
0.00

0.00

Pension Alimony Other income (Please explain on reverse side.)

$ $ $

0.00
0.00

0.00

0.00

TOTAL MONTHLY INCOME FROM ALL SOURCES: The petitioner further represents that the total value of the petitioner's household assets (bank accounts, etc.) is: The petitioner further represents that the basic expenses of the petitioner's household (broken down monthly) are: Rent or mortgage Utilities Food $ $ $
0.00

$ $

0.00
0.00

Medical and Dental Clothing Other (Please explain on reverse side.)

$ $ $
0.00

0.00
0.00

0.00 0.00

0.00

Total Monthly Expenses $ The petitioner further represents that the number of household members (including the petitioner) supported by the petitioner is WHEREFORE THE PETITIONER REQUESTS that the Court grant a waiver of payment of: Application Fee State Marshal's Fees Other costs/fees (Explain below.)

related to the aforementioned proceeding before this Court due to his or her inability to pay for such fees and costs. The representations contained herein are made under the penalties of false statement. Date: ......................................................................... Petitioner:

COURT OF PROBATE, DISTRICT OF PRESIDING JUDGE: Hon. The foregoing request having been presented to this Court, the COURT FINDS that the above-named petitioner to a waiver of fees and costs as indicated above.

DISTRICT NO.

is

is not entitled

WHEREFORE it is ORDERED and DECREED that a waiver of payment of all court costs and fees as indicated above is denied.

is granted

Dated at:

,Connecticut, on [Month, Day, Year] ................................................................. Judge

REQUEST/ORDER WAIVER OF FEES - PETITIONER PC-184

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