Fee Waiver 2 – Motion – Financial
Form Number	Form Name	
GR 34.0100	Motion and Declaration for Waiver of Civil Fees and Surcharges 	
GR 34.0300	Financial Statement	
Quick Instructions: 	
	1.	Review the form. Make changes if needed	
	2.	Date and sign in 3 places:
•	On page 1 of the motion (Basis)
•	On page 2 of the motion (Declaration)
•	At the bottom of the Financial Statement	
	3.	Make a copy to keep for yourself	
	4.	Bring (or mail) the original to court
(Take off this cover sheet first!)	

Superior Court of Washington
For County of Wahkiakum

Shane-Michael T. Renecker	
	Petitioner/Plaintiff,
                                   vs.
Amielia Elizabeth Renecker	
	Respondent/Defendant.
	No.  _______________________

Motion and Declaration For Waiver of Civil Fees and Surcharges
(MTWVF)	

I.  Motion

1.1	I am the [x] petitioner/plaintiff [ ] respondent/defendant in this action. 

1.2	I am asking for a waiver of fees and surcharges under GR 34. 

II.  Basis for Motion

2.1.	GR 34 allows the court to waive “fees or surcharges the payment of which is a condition precedent to a litigant's ability to secure access to judicial relief” for a person who is indigent. As outlined below, I am indigent.

Dated:  			
		Signature of Requesting Party

		Shane-Michael T. Renecker	
		Print or Type Name

III.  Declaration

I declare that,

3.1 	I cannot afford to meet my necessary household living expenses and pay the fees and surcharges imposed by the court.  Please see the attached Financial Statement, which I incorporate as part of this declaration.  

3.2	In addition to the information in the financial statement I would like the court to consider the following:

	

	
	
	.

[x]	(Check if applies.) I filed this motion by mail.  I enclosed a self-addressed stamped envelope with the motion so that I can receive a copy of the order once it is signed.

I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

Signed at (city) Olympia, (state) Washington on (date) ______________.

		Shane-Michael T. Renecker		
Signature		Print or Type Name

Case Name: Renecker v. Renecker  Case Number:  _______________________

Financial Statement (Attachment)	
1.  My name is:  Shane-Michael T. Renecker	
2.  [x] I provide support to people who live with me:  How many? 1	Age(s): 4	
3.  My Monthly Income:	6.  My Monthly Household Expenses:	
Employed  [ ]           Unemployed [x]	Rent/Mortgage:	$      400.00	
Employer’s Name: 	Food/Household Supplies:	$      100.00	
Gross pay per month (salary or hourly pay):		Utilities:	$ 	
Take home pay per month:		Transportation:	$      100.00	
4.  Other Sources of Income Per Month in my Household:	Ordered Maintenance actually paid:	$ 	
Source:	SSI	$      864.00	Ordered Child Support actually paid:	$ 	
Source:	 	$ 	Clothing:	$ 	
Source:	 	$ 	Child Care:	$ 	
Source:	 	$ 	Education Expenses:	$ 	
Sub-Total:	$      864.00	Insurance (car, health):	$       56.00	
 [x] I receive food stamps.	Medical Expenses:	$ 	
Total Income, lines 3 (take home pay) and 4:	$      864.00	Sub-Total:	$      656.00	
5.  My Household Assets:	7.  My Other Monthly Household Expenses:	
Cash on hand:	$        35.00	 	$ 	
Checking Account Balance:	$        14.00	 	$ 	
Savings Account Balance:	$ 	 	$ 	
Auto #1 (Value less loan):	$    1,200.00	 	$ 	
Auto #2 (Value less loan):	$ 	Sub-Total:	$        0.00	
Home (Value less mortgage):	$  	8.  My Other Debts with Monthly Payments:	
Other:  	$ 	Credit Card Payment	$       60.00	/mo	
Other:  	$ 	 	$ 		/mo	
Other:  	$ 	 	$ 	/mo	
Other:  	$ 	 	$ 	/mo	
Other:  	$ 	Sub-Total:	$       60.00	
Total Household Assets:	$    1,249.00	Total Household Expenses and Debts, lines 6, 7, and 8:	$      716.00	
Date:   	Signature: