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Motion And Affidavit For Waiver Of Mediation Fees - Florida

Motion And Affidavit For Waiver Of Mediation Fees Form. This is a Florida form and can be used in Mediation 5th District District Courts Of Appeal Appellate Courts .
 Fillable pdf Last Modified 7/19/2010
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IN THE DISTRICT COURT OF APPEAL OF THE STATE OF FLORIDA FIFTH DISTRICT _________________________, Appellant(s), v. _________________________, Appellee(s). _____________________________/ DATE: ____________________ MOTION FOR WAIVER OF MEDIATION FEES Appellant(s) Appellee(s) _________________________________ through Appellate Case No. 5D__________ _______________________County Case No: ____________________ undersigned counsel, hereby move(s) for waiver of mediator's fees and, in support thereof, submits the attached affidavit, and would state that payment of such fees would create an undue financial burden for the following reasons: ______________________________________________________________________ ______________________________________________________________________ I hereby certify that the above information is true and correct. _______________________________ Appellant(s) Appellee(s) (Name) __________________________ (Address) _________________________ (City/State/Zip) ______________________ ________________________________ Attorney for Appellant(s) Appellee(s) (Name)________________________________ (Address)______________________________ (City/State/Zip)__________________________ NOTE: Signatures by both party and counsel are required. CERTIFICATE OF SERVICE (Counsel's Certificate of Service that complies with Florida Rule of Appellate Procedure 9.420(d)(1) must be attached to this motion) This motion and attached affidavit should be forwarded to: Penny H. Cooper, Mediation Coordinator Fifth District Court of Appeal, 300 S. Beach St., Daytona Beach, FL 32114. Rev. 02-2007 American LegalNet, Inc. www.FormsWorkflow.com IN THE DISTRICT COURT OF APPEAL OF THE STATE OF FLORIDA FIFTH DISTRICT ______________________, Appellant(s), v. ______________________ Appellee(s). _____________________________/ AFFIDAVIT IN SUPPORT OF MOTION FOR WAIVER OF MEDIATION FEES I, , being first duly sworn, depose and make under oath the following statement regarding my age, marital status, dependents and financial condition. AGE: MARITAL STATUS: FINANCIAL CONDITION: Affiant's Gross Income: Weekly $ Bi-Weekly $ Bi-Weekly $ No No Monthly Payments $ Monthly $ Monthly $ DATE OF BIRTH: Married Separated DEPENDENTS: Divorced Single Appellate Case No. 5D________ _________________ County Case No: __________________ Spouse's Gross Income: Weekly $ Own Home Rent Home Yes Yes Monthly Rent Payment $ Value of Real Estate Owned [home, lot(s), etc.]: $ Own Automobile Value of automobile $ Yes No Monthly Payment $ Year/Make $ Value of Personal Property Owned (boats, stocks, jewelry, etc.) Value of Personal Debt By: Signature of Affiant STATE OF FLORIDA COUNTY OF SWORN TO AND SUBSCRIBED TO BEFORE ME THIS Personally known to me Produced identification: DAY OF $ Address: , 200 My Commission Expires: Notary Public, State of Florida Rev. 02-2007 American LegalNet, Inc. www.FormsWorkflow.com
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