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Affidavit In Support Of Application For Proceeding In Custody Or Visitation Case Without Payment Of Fling Fees DC-606 - Virginia
| Affidavit In Support Of Application For Proceeding In Custody Or Visitation Case Without Payment Of Fling Fees Form. This is a Virginia form and can be used in Child Custody District Court Statewide . |
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AFFIDAVIT IN SUPPORT OF APPLICATION FOR PROCEEDI NG IN CUSTODY OR VISITATION CASE WITHOUT PAYMENT OF FIL ING FEES Commonwealth of Virginia Va. Code 16.1-69.48:5 [ ] Circuit Court ........................................................................ ......... [ ] Juvenile and Domestic Relations District Court In re:........................................................................ ............................................................................ The undersigned applicant requests the court to permit the applicant to proceed with a custody or visitation proceeding in this court without the payment of filing fees. In support of this application, the applicant states that the following information is true: 1. The undersigned applicant is a Virginia resident. 2. The following financial information applies to the applicant: a. Receiving public assistance [ ] No [ ] Yes-See items checked below [ ] Medicaid [ ] Supplemental security income [ ] TANF [ ] Food stamps b. Take-home pay $ ................................. per [ ] week [ ] every second week [ ] twice a month [ ] month c. Other income, if any (specify sources and amounts): ....................................................................... ................................................................................... d . Assets Cash on hand $ ......................................... Bank accounts $ ....................................... e. Exceptional Expenses (Total Exceptional Expenses of Family) Medical Expenses (List only unusual and continuing expenses) $ ....................................... Court-ordered support payments/alimony $ ....................................... Child Care payments $ ....................................... Other (Describe on reverse) $ ....................................... 3. Other information a. The number of people for whom the applicant provides support is: ........................................................ b. The number of persons residing with the applicant is: ........................................................................ ... ............................................................ _______________________________________________________________ DATE SIGNATURE APPLICANT ....................................................................... .............. NAME OF APPLICANT Acknowledged, subscribed and sworn to before me this day: ............................................................ ____________________________________________________ DATE [ ] CLERK [ ] DEPUTY CLERK [ ] INTAKE OFFICER [ ] NOTARY PUBLIC (My Commission Expires: ............................) ORDER The request to proceed without payment of filing fees is [ ] granted [ ] denied. If this application is denied, the case will not be set for hearing until the applicable fee is paid to the clerk. ............................................................ _______________________________________________________________ DATE JUDGE FORM DC-606 (PAGE ONE OF ONE) 7/03 PDF American LegalNet, Inc. www.USCourtForms.com
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