Fee Waiver Request {MC 20}

Plaintiff222s/Petitioner222s name vDefendant222s/Respondent222s namePlaintiff222s/Petitioner222s attorney, and bar no.Defendant222s/Respondent222s attorney and bar no. Probate In the matter of en-US en-USInstructions:en-US Complete the form and file it with the clerk. After you receive a decision on your request, you en-USmust serve your request and the decision on the other party.en-USI request a waiver of my filing fees for the following reason: en-US(Check 1, 2, or 3) þ 1. þ I receive the following type(s) of public assistance because of indigence: þ þ Food Assistance Program through the State of Michigan (also known as FAP or SNAP) þ þ Medicaid (including Healthy Michigan, CHIP, and ESO) þ þ Family Independence Program through the State of Michigan (also known as FIP or TANF) þ þ Women, Infants, and Children benefits (WIC) þ þ Supplemental Security Income through the federal government (SSI) þ þ Other means-tested public assistance: en-US þ My public assistance case number(s) (if any) is en-USDo not include your Social Security number.en-US . þ 2. þ I am represented by a legal services program or I receive assistance from a law school clinic because þ of indigence. The name of the legal services program or law school clinic is þ en-US en-US . þ 3. þ I am unable to pay the fees. þ My gross household income is $ en-US en-US every en-USWeek/Two weeks/Month/Year . þ þ The number of people in my household is en-US en-US . þ My source of income is en-US en-US . þ en-USList assets and their worth, such as bank accounts. If you need more space, attach a separate sheet. þ þ en-USList obligations and how much you pay, such as rent or other debts. If you need more space, attach a separate sheet.en-USI declare under the penalties of perjury that this request has been examined by me and that its contents en-USare true to the best of my information, knowledge, and belief. en-USDate þ en-USSignature þ FOR CLERK USE ONLY: en-USPayment of filing fees is waived. en-US en-USDate þ en-USSignature of court clerk American LegalNet, Inc. www.FormsWorkFlow.com Case No. en-USIT IS ORDERED: þ 1. Payment of filing fees is waived because: þ þ a. þ The applicant222s gross household income is under 125% of the federal poverty level. þ þ b. þ Other: þ þ You must notify the court if you become able to pay the fees before this case is resolved. þ 2. þ The fee waiver request is denied. To continue your case, you have 14 days from the date of this order þ to pay the filing fees or request a review. To request a review, complete and file the request for review þ (form MC 114). þ The reason for denial is: þ en-USDate þ Judge þ Bar no. en-USORDER American LegalNet, Inc. www.FormsWorkFlow.com