Office of Dispute Resolution

Office of Dispute Resolution

SEVENTH JUDICIAL ADMINISTRATIVE DISTRICT

P.O. BOX 963 PHONE: (770) 387-4820

CARTERSVILLE, GA 30120 TOLL FREE: (877) 655-6865

www.7jad.com FAX: (770) 387-5479

Indigent Fee Waiver Form

The party requesting a fee waiver/fee reduction for the cost of mediation should complete this form and return it to the above address. This form must be received by the ADR Office ten (10) days prior to the mediation session. Late or incomplete forms will not be accepted. The requesting party is responsible for notifying the mediator of the results prior to the mediation session. If you need assistance, please call the ADR Office.

Name: (Last, First MI) Civil Action #

Mail Address Style of Case (example: Doe vs Doe)

City, State and Zip County

Phone Assigned Judge

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 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 the Plaintiff / Defendant (CIRCLE ONE) in the above referenced case which has been referred by the assigned judge to mediation. Affiant is unable to pay (select one of the following):

____Any of the mediation costs of this action and is therefore requesting a fee waiver.

____All of the mediation costs in this action and is therefore requesting a fee reduction.

____Affiant states that mediation fees can be paid so long as fees do not exceed $________.

SECTION 3

Affiant provides the following information:

1. Are you working? Y / N Name of Employer: _____________________________

2. Net Income: ______________________ (Monthly)

3. List every source and amount of additional income: This includes child support, alimony, welfare, social security, workman’s comp, unemployment, food stamps, or disability. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. List everyone that lives in your home:

Name Relationship / Age Net Income

_________________________ __________________________ ________________

5. Do you own your home? Y / N Value _______________

6. List Checking, Savings or Money Market Accounts

Institution Type / Account No. Balance

__________________________ _______________________ _________________

7. List any other property of value (jewelry, real estate, etc.) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Amount of monthly house payment or rent ____________________

9. List all indebtedness

Creditor Account No. Balance Monthly Payment

______________________ ___________________ _____________ _______________

10. List any extraordinary living expenses and amounts (such as regularly occurring medical expenses, prescriptions, childcare, etc.) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

SECTION 4

Affiant states that (select one of the following):

______ she/he represents herself/himself in this action.

______ she/he is represented by counsel and counsel has not yet been paid.

______ she/he is represented by counsel at no expense.

SECTION 5

The undersigned Affiant swears the information given herein is true and correct and understands that a false answer to any item may result in prosecution for a felony and/or contempt of Court.

FURTHER SAITH THE AFFIANT NOT.

This ___________ day of ____________________, 20_______.

_______________________________________

Affiant’s Signature

Sworn to and subscribed before me

This ___________ day of ____________________, 20_______.

______________________________

Notary Public

My commission expires ________________.