Free Filing Fee Waiver Request - New Jersey

___________________________ Plaintiff

NEW JERSEY JUDICIARY

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FILING FEE WAIVER REQUEST
Based on Inability to Pay
VS. ___________________________ Defendant Applicant's Name: Last: Home Address: Docket Number: First: MI: Home Phone #: ( ) Number of Dependants City: ______________________ State: ______ Zip: _______ I, __________________________________, am over the age of 18 and request no court fee be charged as I am without funds to pay the fee. I am a (check one) Plaintiff Defendant in the following court: Civil Special Civil Part General Equity Probate The following are facts about my financial condition. My income before taxes is: Salary (per month): $ Other Income (per month): $ Specify source of other income, including six months of prisoners' account statements in accordance with N.J.S.A. 30:4-16.3 (per month):

Street: ______________________________ Apt No.: ______

The following is a complete list of everything I own and owe, as far as I know: Own Amount $ Owe (per month) Amount $ Money in any bank accounts Rent/mortgage Automobiles Food Real estate Utilities Insurance with cash value Alimony/child support Money owed to me Auto payment Other (specify) Other (specify) TOTALS TOTALS 0 0

Please attach documents as to income (pay stubs, welfare documents, unemployment documents, last bank statement, etc.) I certify the statements made by me in this document are true and that my proposed pleading is attached. I understand that if I give any false information, I may be punished by the court.
I am signing this statement to explain to the court why I am unable to pay any court fees in this lawsuit. (Rule 1:13-2(a))

Fee Waived:
Signature (Applicant): Date: _______________________________________ (Print Name)
Published 03/25/2008, CN 11208-English

Yes

No

Signature (Judge): Date: ________________________________________ (Print Name)
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