Request Order Waiver Of Fees - Respondent {PC-184A} | Pdf Fpdf Docx | Connecticut

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Request Order Waiver Of Fees - Respondent {PC-184A} | Pdf Fpdf Docx | Connecticut

Request Order Waiver Of Fees - Respondent {PC-184A}

This is a Connecticut form that can be used for Probate within Statewide.

Alternate TextLast updated: 9/26/2018

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CONNECTICUT PROBATE COURTS Request/Order Waiver of Fees - PC-184 REV. 10/15 RECEIVED: Instructions: 1) A in a probate matter may use this form to establish that he or she is indigent and unable to pay Probate Court Name District Number In the Matter of Type of Matter The undersigned represents that: 1) The total number of the dependents (exclude ) is 205205205205205205205205205205205205205205205205205205.. 2) The gross monthly income from employment is 205205205205205205205205. 3) The net monthly income from employment after taxes and other mandatory payroll deductions is205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205. 4) The net monthly income from employment of all other members of household after taxes and other mandatory payroll deductions is205205205.205205205205205205205205205205205205205..205 5) Other monthly income (include income to and other members of the household) is: a)Public Assistance (Specify.)b)Social Security205205205205205205205205205205205205205205205205205205205205205205205205..c)Pension 205205205205205205205205205205205205205205205205205205205205205205205205205205205.d)Unemployment Compensation 205205205205205205205205205205205205205205205205205..e)Other (Specify.) Total other monthly household income (Items 5a through 5e above)205205205205205205205......205. Total net monthly household income (Items 3,4 and 5 above)205205..205205..205205205205205205205.205.. The undersigned further represents that: 1) Estimated value of assets owned by and other members of the household: a)Real estate Outstanding mortgage Net value205 b)Motor Vehicles Outstanding loans Net value205 c)Balance of all savings accounts 205205205205205205205205205205205205205205205205205205205..205d)Balance of all checking accounts 205205205205205205205205205205205205205205205205205205205205e)Cash 205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205f)Other assets (specify) T otal net value of the household assets ( Items 1a through 1 f above ) 205205 205205205205205205205205205205205 Request/Order Waiver of Fees - PC-184 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Request/Order Waiver of Fees - PC-184 REV. 10/15 2) The liabilities/debts of the household are (excluding above mortgages/loans): a)Credit card balance205205205205205205205205205205205205205205205205205205.b)Other (specify) 3) The estimated monthly expenses of the household are: a)Rent/Mortgage205205205205205205205205205205205205205205205205205205205..b)Property Taxes205205205205205205205205205205..205205205205205205205205205.c)Utilities205205205205205205205205205205205205205205205205205205205205205205205.d)Food205205205205205205205205205205205205205205205205205205205205205205205205.e)Medical and Dental205205205205205205205205205205205205205205205205205205f)Insurance premiums (medical, auto, home, etc.)205205205205205..g)Clothing205205205205205205205205205205205205205205205205205205205205205205205.h)Child Care205205205205205205205205205205205205205205205205205205205205205.205i)Car loan205205205205205205205205205205205205205205205205205205205205205205205.j)Minimum monthly credit card payment205205205205205205205205205205k)Other transportation costs (bus, gasoline)205205205205205205205205.l)Other (specify) Total Monthly Household Expenses (Items 3a through 3l above205205205205205205205205205205205205 The undersigned requests that the court grant a waiver of fees and expenses in the above matter for which the may be responsible because the is indigent and unable to pay the fees and expenses. The representations made in this petition are made under the penalty of false statement. Signature Title (if applicable) Type or Print Name Date COURT OF PROBATE, D PRESIDING JUDGE: Hon. The foregoing request having been presented to the court, the COURT FINDS that the : is indigent and entitled to a waiver of fees and expenses as requested above. is not indigent. WHEREFORE, it is ORDERED and DECREED that a waiver of fees and expenses for which the may be responsible is: granted denied. Dated at , Connecticut, on [Month, Day, Year] 205205205205205205205..205205205205205205205205. Judge For Court Use Only Request/Order Waiver of Fees - PC-184 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com

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