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New Submission Page 1 of 5 r COLUMBIA JUDICIAL CIRCUIT ADR PROGRAM Serving Columbia County 640 Ronald Reagan Drive · Evans, Georgia 30809 Fee Waiver Application INSTRUCTIONS: Any party requesting a fee waiver or a fee reduction for the cost of mediation must complete this form and submit it to the Columbia Judicial Circuit ADR Program within ten (10) days of the Order of Referral for Mediation. The party requesting a fee waiver or a fee reduction will be notified whether the request is granted or denied prior to the mediation session. Any of the following will result in automatic disqualification of a fee waiver or a fee reduction, regardless of the person’s ability to pay: Fee waiver applications received after 10 day from order of referral; Incomplete applications; Failure to disclose accurate financial information. Applicant Name* County* Plaintiff's Name* Defendant's Name* Civil Action File No* Judge The following information given herein is true and correct to the best of my knowledge: A fee waiver or fee reduction is only available for mediation services provided by the Columbia Judicial Circuit ADR Program. Information ---PAGE BREAK--- New Submission Page 2 of 5 Current Employer Supervisor's Name If Unemployed, how long? Supervisor's Phone Number Reason Unemployed List all children under the age of 18 and all other persons living in your home: Name Relationship Age Add My Wages Spouse's Wages (if not separated) Other Adult Household Member Wages (if applicable) Complete all applicable fields below: Alimony Received Employment Dependants Income After taxes and allowable deductions. NOTICE: You are required to attach proof of income with this application or your application will not be considered regardless of your ability to pay. $ Upload My Proof of Income Upload After taxes and allowable deductions. NOTICE: You are required to attach proof of income with this application or your application will not be considered regardless of your ability to pay. $ Upload Spouse's Proof of Income Upload After taxes and allowable deductions. NOTICE: You are required to attach proof of income with this application or your application will not be considered regardless of your ability to pay. $ Upload Adult Household Member's Proof of Income Upload $ ---PAGE BREAK--- New Submission Page 3 of 5 Alimony Received Child Support Received Pension/Retirement Benefits Social Security Benefits Unemployment Benefits Workers' Compensation TANF/SNAP Rental Income Other Income Total Income Money in Checking or Savings Account Real Estate (List Current Market Value) Amount Owed Description (Home, Land, Building, etc.) Property Owner Add Vehicle (Current Market Value) Amount Owed Description (Car, Truck, Boat, RV, etc.) Titled/Registered in whose name? Add Other Assets (jewelry, electronics, etc.) Total Assets Alimony Ordered to Pay Child Support Ordered to Pay $ $ $ $ $ $ $ $ $ $ 0.00 Assets $ $ $ $ $ $ $ 0.00 Debts $ $ ---PAGE BREAK--- New Submission Page 4 of 5 Pay Unusually Large Bills or Extraordinary Living Expenses Description Add Amount of House Payment or Rent You Pay Total Debts Applicant states that* Signature* Application Date* Email Address Mailing Address* Primary Phone* Secondary Phone $ $ $ 0.00 Legal Representation I represent myself in this action. I am represented by a paid attorney. I am represented by an attorney at no expense (pro bono). Sworn Statement Sign I certify that I am financially unable to pay for ADR Services without causing substantial hardship to myself or my family. I certify that all information given herein is true and correct to the best of my knowledge. I understand that making a false statement and/or failing to disclose accurate information will result in automatic disqualification of a fee waiver or a fee reduction, regardless of my ability to pay. 3/29/2021 City State / Province / Region Postal / Zip Code Country Street Address Address Line 2 ---PAGE BREAK--- New Submission Page 5 of 5 COLUMBIA JUDICIAL CIRCUIT ADR PROGRAM Serving Columbia County 640 Ronald Reagan Drive · Evans, Georgia 30809 Submit Save as Draft