Complete this form and file it with the court. If this request is filed by a prisoner, a certified statement of the
prisoner’s trust account showing a current balance and a 12-month history of deposits and withdrawals must accompany
this form. After you receive a decision on your request, you must serve your request and the decision on the other party(ies).
JIS Code: OSF
FEE WAIVER REQUEST
STATE OF MICHIGAN
JUDICIAL DISTRICT
JUDICIAL CIRCUIT
COUNTY
CASE NUMBER and JUDGE
Court address
Court telephone number
Plaintiff/Petitioner’s name, address, and telephone number
Plaintiff/Petitioner’s attorney, bar number, address, and telephone number
V
Defendant/Respondent’s name, address, and telephone number
Defendant/Respondent’s attorney, bar number, address, and
telephone number
In the matter of
Instructions:
I request a waiver of my filing fees for the following reason:
(Check 1, 2, or 3)
1. I receive the following type(s) of public assistance because of indigence:
Food Assistance Program through the State of Michigan (also known as FAP or SNAP)
Medicaid (including Healthy Michigan, CHIP, and ESO)
Family Independence Program through the State of Michigan (also known as FIP or TANF)
Women, Infants, and Children benefits (WIC)
Supplemental Security Income through the federal government (SSI)
Other means-tested public assistance:
My public assistance case number(s) (if any) is
.
Write “none” if no case number. Do not write your Social Security Number
2. I am represented by a legal services program or I receive assistance from a law school clinic because of indigence.
The name of the legal services program or law school clinic is
.
3. I am unable to pay the fees and I did not check item 1 or 2 above.
My gross household income is $ every
Week/Two weeks/Month/Year
.
The number of people in my household is
.
My source of income is
.
List assets and their worth, such as bank accounts. If you need more space, attach a separate sheet.
List obligations and how much you pay, such as rent or other debts. If you need more space, attach a separate sheet.
I declare under the penalties of perjury that this request has been examined by me and that its contents are true to the
best of my information, knowledge, and belief.
Date Signature
Approved, SCAO
Form MC 20, Rev. 9/23
MCR 2.002
Page 1 of 2
Distribute form to:
Court
Applicant
Other parties
Friend of the court (when applicable)
Choose Option 1, 2, or 3
SRA
Case Number
Fee Waiver Request
(9/23)
Page 2 of 2
CLERK WAIVER
1.Payment of filing fees is waived.
Signature of court clerk and date
ORDER
IT IS ORDERED:
1. Payment of filing fees is waived because:
a. Your gross household income is under 125% of the federal poverty guidelines.
b. Your gross household income is above 125% of the federal poverty guidelines,
but payment of the fees would constitute a financial hardship for you.
c. Other:
If you become able to pay the fees before this case is resolved, you must notify the court.
2. The fee waiver request is denied because:
a. Your gross household income is above 125% of the federal poverty guidelines and payment of the fees
would not constitute a financial hardship for you
b. Other:
Judge/Magistrate (when authorized) signature and date
IF YOUR REQUEST WAS DENIED: To continue your case and preserve your filing date, you have 14 days from the issue
date below to pay the filing fees or request a review. To request a review, fill out a Request for Review of Denied Fee Waiver
(form MC 114) and file it with the court.
NOTICE
Issue date (completed by clerk)
