Fee Waiver 3 – Order	  	
This is a proposed court order for a Judge to approve.	
Form Number	Form Name	
GR 34.0500	Order re Waiver of Civil Fees and Surcharges	
Quick Instructions: 	
	1.	Review the form. Make changes if needed.	
	2.	Date and sign by your name only.  
(Not where the Judge or Commissioner signs)	
	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.  _______________________

Order Re Waiver of Civil Fees and Surcharges
[  ] Granted (ORPRFP)
[  ] Denied (ORDYMT)
[  ] Clerk’s Action Required 3.1	

I.  Basis

The court received the motion to waive fees and surcharges filed by or on behalf of the 
[ ] petitioner/plaintiff  [x] respondent/defendant. 

II.  Findings

The Court reviewed the motion and supporting declaration(s).  Based on the declaration(s) and any relevant records and files, the Court finds:
 
2.1 	[x]	The moving party is indigent based on the following:  He or she:

[  ]	is represented by a qualified legal aid provider that screened and found the applicant eligible for free civil legal aid services; and/or

[x]	receives benefits from one or more needs-based, means-tested assistance programs; and/or

[x]	has household income at or below 125% of the federal poverty guideline; and/or 

[ ]	has household income above 125% of the federal poverty guideline but cannot meet basic household living expenses and pay the fees and/or surcharges; and/or

[  ]	other:  	
	
	.
2.2  	[  ]	The moving party is not indigent.

2.3	[  ]  	Other:	

	
	
	.

III.  Order

Based on the findings the court orders:

3.1	[x]	The motion is granted, and 

[x]	all fees and surcharges the payment of which is a condition precedent to the moving party’s ability to secure access to judicial relief are waived.

[  ]	other:  	

	
	
	.

3.2 	[  ]	The motion is denied. 

Dated: 			
							Judge/Commissioner

Presented by:

Signature of Party or Lawyer/WSBA No.

Amielia E, Renecker		______________	
Print or Type Name	Date