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Civil Action File No.: _ Page 1 of 4 Columbia Judicial Circuit ADR Program Fee Waiver or Reduction Application I, have been referred to the Columbia Judicial Circuit ADR Program. I do not have the funds to pay the program rate and hereby request a fee waiver or fee reduction. The following information herein is true and correct to the best of my knowledge: I am the (Select One: Plaintiff / Defendant) in the above-referenced case. Name of Attorney (if represented): FEE WAIVER APPLICATION INSTRUCTIONS: Any party requesting a fee waiver or 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 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 fee reduction, regardless of the person’s ability to pay: Fee waivers received after 10 days from Order of Referral; Incomplete applications; Failure to disclose requested financial information. A fee waiver or reduction is only available for mediation services provided by the Columbia Judicial Circuit ADR Program. First Name: Last Name: County where case is filed: Date of Application: Case Caption: vs. Civil Action File No.: Judge: COLUMBIA JUDICIAL CIRCUIT ADR PROGRAM Serving Columbia County 640 Ronald Reagan Drive ∙ Evans, Georgia 30809 ---PAGE BREAK--- Civil Action File No.: _ Page 2 of 4 Columbia Judicial Circuit ADR Program Fee Waiver or Reduction Application EMPLOYMENT: Current Employer: Supervisor’s Name and Phone If Unemployed, how long? Reason Unemployed: DEPENDENTS: List all children under the age of 18 and all other persons living in your home: # NAME RELATIONSHIP AGE 1 2 3 4 5 6 NET INCOME Wages Self – After taxes and allowable deductions NOTICE: You are required to attach a recent paycheck stub or other proof of income hen submitting this Form. Your application will not be considered without providing proof of income. Wages Spouse (if not separated) – After Taxes NOTICE: A copy of a recent paycheck stub or other proof of income must be submitted with this form. Wages Other household members who contribute to household income - After Taxes Alimony or Child Support received Social Security, VA, Welfare, Food Stamps or other assistance program. List type of assistance: Other interest, dividend, rent, IRA, C.D. acct., etc.) Source of other income: Money or other assistance received from non-household member Name of source and relationship: TOTAL NET INCOME ---PAGE BREAK--- Civil Action File No.: _ Page 3 of 4 Columbia Judicial Circuit ADR Program Fee Waiver or Reduction Application ASSETS Cash on hand or any money not in a bank Money in checking or savings account Real Estate (home, land, buildings, etc.) List current market value below: Amount owed: $ Listed in whose name? Vehicles – car, truck, boat, tractor, van, RV, etc. List current market value: Amount owed: $ Titled/Registered in whose name? Other assets (list) jewelry, camper, wide screen TV, etc. List current market value: TOTAL ASSETS DEBTS Alimony or child support ordered to pay. Unusually large bills or extraordinary living expenses. Explain: Amount of house payment or rent you pay. TOTAL DEBTS REQUIRED: Please select one of the following statements that most accurately describes your representation in this case. I represent myself in this action. I am represented by an attorney and my attorney has not yet been, I am represented by an attorney and I have not yet paid my attorney in full. I am represented by an attorney at no expense. ---PAGE BREAK--- Civil Action File No.: _ Page 4 of 4 Columbia Judicial Circuit ADR Program Fee Waiver or Reduction Application SWORN STATEMENT I, am financially unable to pay for ADR services without causing substantial hardship to myself or to my family. I certify that all statements given herein are 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 reduction, regardless of my ability to pay. This day of 20 Applicant’s Signature Email Address: Mailing Address: Primary Phone: Secondary Phone: SIGN