Poverty Fee Reduction Application

POVERTY FEE REDUCTION APPLICATION NINTH JUDICIAL ADMINISTRATIVE DISTRICT OFFICE OF DISPUTE RESOLUTION P. O. Box 1236 501 Candler Street NE Gainesville, Georgia 30503 Telephone: 770.535.6909 Facsimile: 770.531.4072 PLEASE READ CAREFULLY AND COMPLETE EXACTLY AS DIRECTED Parties who feel they qualify for a fee reduction may access our form and download it from our website at www.adr9.com. The original form must be submitted to our office. We cannot accept a faxed or emailed copy. The Fee Reduction Request Form must be received in the 9th JAD ODR ten (10) working days (Monday thru Friday, 8:30 am ­ 5:00 p.m.) prior to the scheduled mediation session or seminar date. Any of the following will result in automatic disqualification for a fee reduction, regardless of the person's ability to pay: Fee reduction requests received less than ten (10) days prior to the scheduled mediation session or seminar date; incomplete case and/or personal information; Failure to disclose requested financial information; False or incomplete information; Improperly completed applications. APPLICATION RE-SUBMISSIONS WILL NOT BE ACCEPTED. If you have questions about this form, please call 770.535.6909 between 8:30 a.m. and 5:00 p.m. It is the responsibility of the party requesting the fee reduction to contact our office prior to your date for mediation or seminar to determine if you qualify for a fee reduction. ONCE SUBMITTED YOU CANNOT CHANGE THIS FORM. Last Name of Party Requesting Reduction: _____________Middle Name:______________First Name:__________________ Mailing Address: _________________________________________City, State & Zip: ________________________________ Physical Address: _________________________________________City, State & Zip:_________________________________ Telephone Numbers: Home: _________________ Work: ________________Cell: __________________ Other:___________ Court Case Name/Style: ______________________________________Civil Action Filing Number: _____________________ Date of Birth:_____________ County in which Case is Filed: _________________ Assigned Judge:_____________________ Social Security Number:_________________ IF ABOVE CASE INFORMATION SECTION IS NOT FILLED OUT COMPLETELY, YOUR REQUEST FOR A FEE REDUCTION WILL NOT BE CONSIDERED. I__________________________, personally appeared before the undersigned officer duly authorized to administer oaths in the State of Georgia, and having been sworn, state the following: Section 1. Affiant, you, is a United States citizen above the age of eighteen (18) years, under no legal disability, and has personal knowledge sufficient to make this affidavit in connection with the above-styled action. Section 2. Affiant is a party in the above referenced case which has been referred to the Office of Dispute Resolution for _______MEDIATION ______SEMINAR ______BOTH. Affiant is unable to pay normal fee rates. Section 3. Affiant provides the following information: Name of Current Employer________________________Supervisor Name and Telephone Number_____________________ If unemployed: How long unemployed? _________________ Most recent Employer__________________________________ Reason (s) for Unemployment _______________________________________________________________________________ If Disabled, list diagnosis___________________________________________________________________________________ Section 4. School or College Attending:________________________________ Financial Aid Amount from school, companies, clubs, government or churches:$___________________________ American LegalNet, Inc. www.FormsWorkFlow.com DEPENDENTS ­ List all children that you have custody of under the age of 18 living in your household Name Relationship Age Name Relationship Age __________________________________ ____ _______________________________ ____________ _______________________________________ _______________________________ ____________ _______________________________________ _______________________________ ____________ LIST - all other persons in the household in which you are residing not listed above as dependents: Name Relationship _______________________________________ _______________________________ _______________________________________ _______________________________ _______________________________________ _______________________________ _______________________________________ _______________________________ INCOME Wages Affiant $__________Gross per month (copy of recent paycheck stub required and to be submitted with this form) If paystub is not submitted, your application will not be considered Other Household Member Age _____________ _____________ _____________ _____________ $__________Gross per month Employer:__________________________ (copy of recent paycheck stub required and to be submitted with this form) Other Household Member $__________Gross per month Employer: ________________________________________________ (copy of recent paycheck stub required and to be submitted with this form) Other Income: $___________per month Alimony or Child Support List type(s) of support: ________________________________________________________ $__________ per month Social Security, VA, Welfare, Food Stamps, Well Care/Peach Care, public housing or HUD housing or other assistance program. List type(s) of assistance_______________________________________________________ $__________per month Other income such as interest income, dividends, rent, royalties, or from any other sources. Source of other income ________________________________________________________ Other assistance received and total amount such as monies from family members, churches, civic organizations or from any other persons or organizations including gifts, use of vehicle, or equipment. Name of Source and relationship, if any ___________________________________________ $__________per month $__________________ TOTAL GROSS INCOME per month and $_______________ TOTAL GROSS INCOME per year ASSETS (If these assets below will increase future interest, please put them in the "Income" section above.) $__________________ Cash on hand or any money not in a bank $__________________ Money in checking, savings or any other financial accounts. List financial institution(s) and amounts ____________________________________________ $__________________ Real Estate (houses, property, buildings, etc.) List current market value. Amount owed $________________________________________________________________ Name of Mortgage H