Application For Waiver {UJS-135}

STATE OF SOUTH DAKOTA COUNTY OF ____________________________ ________________________________________ Plaintiff, vs. ________________________________________ Defendant IN CIRCUIT COURT ______ JUDICIAL CIRCUIT CASE FILE NO: __________________ APPLICATION FOR WAIVER OF $50 FILING FEE FOR THE MODIFICATION OF A FINAL CHILD SUPPORT, CHILD CUSTODY, VISITATION, OR SPOUSAL SUPPORT ORDER Please fill out application completely and accurately. If you don't, it may be denied. I come before the court to make a PETITION to modify an existing child support order; however, I am unable to pay the required $50 filing fee. Therefore, I respectfully request that the court waive the filing fee for this modification. The existing child support order was entered into on: Date The existing child support order was last modified on: Date I (DO) (DO NOT) HAVE A LAWYER Lawyer's Name: (1) (2) (3) (4) (5) (6) (7) (8) (9) My address is: , my date of birth is: My telephone number is: I am (check one) EMPLOYED UNEMPLOYED . (If employed), my weekly take home pay is: $ Retirement, disability, or insurance benefits: $ per was: $ My total income before deductions for year My total income after deductions for year was: $ Including myself, I have the following number of dependants: The following amounts accurately represent my assets and liabilities: I. ASSETS (things I own or am buying) a. CASH (on hand or in banks)......................................................................................................$ b. ACCOUNTS and NOTES RECEIVABLE (IOU's and other money payable to me)....................................$ c. INVESTMENTS (stocks, bonds, savings bonds, etc.).........................................................................$ d. REAL ESTATE (house, land, tribal lease land, rental property, etc.).......................................................$ e. AUTOMOBILE (S) make, model & year: $ f. HOUSEHOLD GOODS (furniture, appliances, TV, stereo, etc.)............................................................$ g. OTHER PERSONAL PROPERTY (tools, sports equipment, etc.)..................................................................$ h. ANY OTHER ASSETS (anything else I could sell or borrow money on).........................................................$ II. LIABILITIES (money that I owe) a. My regular monthly expenses are: (housing utilities, food, etc.).............................................................$ b. LOANS: I owe this amount.......................................................................$ this amount.......................................................................$ I owe I owe this amount.......................................................................$ III. ANITICIPATED INCOME (money or property you are expecting) a. Total monies or income from the sale of house or land, alimony, gifts inheritance, allotments, Trust funds, lease money, etc.......................................................................................................................................$ (10) I affirm the above information is correct and accurate to the best of my knowledge and fully understand any misrepresentation or misleading of fact will subject me to the penalty of perjury. day of , 20 . X , Petitioner SELF EMPLOYED . . Dated this -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------APPROVED ATTEST: DENIED BY THE COURT: CLERK OF COURTS/DEPUTY (SEAL) CIRCUIT COURT JUDGE Form UJS-135 Rev. 09/2009 American LegalNet, Inc. www.FormsWorkFlow.com