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HomeMy WebLinkAbout12-1026 i 1 Request to Waive Court Fees CONFIDENTIAL If you are getting public benefits, are a low-income person, or do not have Clwk sftmps dale here when krm is filed enough income to pay for household's basic needs and your court fees, you may use this form to ask the court to waive all or part ofyour court fees. The cows may order you to answer questions about your finances. If the court waives the fees, you may still have to pay later if --c • You cannot give the court proof of your eligibility, • Your financial situation improves doming this case, or F+:r oarsr Dame and *111 Mri • You settle your civil case for $10,000 or more. The trial court that waives --? your fees will have a lien on any such settlement in the amount of the waived . ' fees and costs. The court may also charge you any collection costs. D ° a o c-) O Your 1 ormation Orson a the ourt waive t e fees): p ? a c=a Name: 0V - X o -M Street or marlin aaddress: r ,, I.L FWircaMm n&wawnwne: , City: 1 't fate: zip case Number. Phone number: - (p f p O Your Job, if you a (job title): t 014) case Name: Name of employer. 7 - ?(" . r - 1 n o _ Employer's address: (t q `, i ' V) C Your lawyer, if you have one (name,?irm or affiliation, address, phone number, and State Bar number): 0, C>) n ?- a. The lawyer has agreed to advance all or a portion of your fees r.wsts (check one): Yes? No N1 b. (If yes, your lawyer must sign here) Lawyer's signature: If your lawyer is not providing legal-aid type services based on your low income, you may have to go to a hearing to explain why you are asking the court to waive the fees. O What court's fees or costs are you asking to be waived? ? Superior Court (See Information Sheet on Waiver of Superior Court Fees and Costs (form FW-001-INFO).) ? Supreme Court, Court of Appeal, or Appellate Division of Superior Court (See Information Sheet on Waiver of Appellate Court Fees and Costs (form APP-0 15/FW-015-INFO).) O Why are you asking the court to waive your court fees? a ? 1 receive (check all that apply): ? Medi-Cal ? Food Stamps ? SSI ? SSP ? County Relief/General Assistance ? IHSS (In-Home Supportive Services) ? Ca1WORKS or Tribal TANF (Tribal Temporary Assistance for Needy Families) ? CAPI (Cash Assistance Program for Aged, Blind and Disabled) b.,® My gross monthly household income (before deductions for taxes) is less than the amount listed below. (If you check Sb you must fill out 7, 8 and 9 on page 2 of this form) Fama t Size Family Income FamBy Sias Family Income Famih? Size Family Irworne If more than 6 eo le 1 $1,134.38 3 $1,93021 5 $2,726.05 p p at home, add $39792 2 $1,532.30 4 $2,328.13 6 $3,123.96 for each extra person. c. ? I do not have enough income to pay for my household's basic needs and the court fees. I ask the court to (check one): ? waive all court fees ? waive some of the court fees ? let me make payments over time O (Explain): (If you check 5c, you must fill out page 2.) 6 ? Check here if you asked the court to waive your court fees for this case in the last six months. (Ifyour previous request is reasonably available, please attach it to this form and check here. ? ) I declare under penalty of perjury under the laws of the State of ,'hat the information I have provided on this form an a chments is true and correct. -all Date: i Pnn your name here S here "' Request to Waive Court Fees FW-001, Page 1 of 2 Your name: Case Number If you checked Sa on page 1, do not fill out below. If you checked Sb, fill out questions 7, 8, and 9 only. If you checked 5c, you must fill out this entire page. Ifyou need more space, attach form MC-025 or attach a sheet ofpaper and write Financial Information and your name and case number at the top. OE] Check here if your income charges a lot from month to month 8 Your money and Property Fig out below based on your average intone for the past 12 months a Cash - - - - - - - - $ OYour monthly Income a. Gross monthly income (before deductions): $ Vi Ali' List each payroll deduction and amount below. (2) $ (3) _ $ (4) $ b. Total deductions (add 89 (1)-(4) above): $ a C. Total monthly take-home pay (8a mba 8b): $-1L 01-00 d. List the source and amount of arw other irx:ome you get each month, including: sporseVdiid support, retirement, social seauiht, disabt, unemployi WK rni'itary basic allowance for quarters (BAO), veterans payments, dividends, interest, trust income, arwRiities, net business or rertat krcorne, reimbursement for jobs expenses, gambling or loft winnings, etc (1) $ (2) $ (3) - $ e. Your total nronift income is (8c plus 8W: $ O D, OD O Household Income a. List at other persons living in your home and their kxxw e; 11 include only your spouse and all individuals vAw depend in whole or in part on you for support, or on whom you depend in whole or in part for support Gross Mouldy Name Age Relationship Income (1) $ ?-- (2) $ (3) $ (4) $ b. To W monthly income of persons above: $ r? Total monthly income and household income (8e plus 9b): $?i?+ To list any other facts you want the court to know, such as unusual medical expenses, family emagencies, etc., attach form MC-025. Or attach a sheet of paper, and write Financial Information and your tune and case number at the top. Check here ifyou attach another page. ? Important! If your financial situation or ability to pay court fees improves, you mast notify the court within five days on form FW-010 b. All financial accourft (List bank name and amount): (1) ` $ 'MOO (z) $ (3) $ (4) C. Cars, boats, and other vehicles Make /Year Fair Market How Much You (} r ? xu ? $ Value C? $Still Owe t 1 d Q? QO (2) $ l r' $ (3) d. Real estate Fair Market Address Value (1) ? "O- $ (2) $ (3) $ How Much You Still Owe $ $ $ e. Ottrer personal property (Pwelry. furniture, furs, stocks, bonds, etc')" Fair Market How Much You Describe Value Still Owe (1) ?1 UI?tC $ $ (2) $ $ $ $ Your Expenses (Do nots aw,uie payrati dedreGnns you aready istled in ad.) EL Rent or house payment & maintenance $ b_ Food and household sug4on $ C. Uffidies and telephone $ cam- O, d. Clothing $ e. Laundry and dearang f ©, © O $- . f Memel and dental expenses $ _ 9- Insurance (fife, heaKh, accident, etc.) $ h. School, child care $ i. Child, spousal support (another marriage) $ ). Tmaporhom, gas, auto repair and insurances • Q0 k. Instalmerht payments (fist each below): Paid to: t1)_ $ - (2) ! $ (3) $ 1. wages e/eaami gs withheld by court order $ -- m- Any other monthly expenses first each bebw). $ --- Paid to: How Much? (9) $ - (2) $ (3) $ TOW more" expenses (add 11a -11m above): $ 7 If©h oo Rev. Fe&uwy 22, 2011 Request to Waive Court Fees FW-0Q1, Page 2 of 2 IN THE COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA CIVIL DIVISION -LAW c q =m ? ?^- 2m co ?r es Xft zo ?s o = IN THE MATTER OF PETITION FOR C NGE OF NAME F _ 4- P)- NO: PL' 16 PETITION FOR CHANGE OF NAME c- Petitioner WNW /,Arequ sts that this Court order a change of the petitioner's name, pursuant to 54 Pa. Cons. Stat. Section 701, et sea., and in support thereof makes the following the averments: 1. The petitioner was born on 0111 , l Mand is over the age of twenty-one years. 2. During the five years preceding the filing of this petition, the petitioner has resided in the following places: Nl ®g DATE ADDRESSES 110ft N 1055 3. There are no judgments or decrees pending against the petitioner. (-Lsuevv 4. The Petitioner requests that his/her name be changed from _ BA T A Zh A A)to _ 5. The reasons for the requested change of name are 40 )Oc? 0&__Q ?-1 ?aSy ?r bus?vi Qt?? _ . l? N 1% WHEREFORE, the petitioner respectfully requests that this Court t enter an Order changing his/her name fromW L4 6 b ? tv ?1 l?v'l A Petitioner 1?1 IN THE MATTER OF PETITION FOR CHANGE OF NAME OF LYUBOV BATAZHAN IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 12-1026 CIVIL TERM IN RE: PETITION FOR LEAVE TO PROCEED IN FORMA PAUPERIS ORDER OF COURT AND NOW, this 15'' day of March, 2012, upon consideration of Plaintiff's Request To Waive Court Fees, the petition is granted, and Plaintiff is authorized to file her Petition for Change of Name without payment of the filing fee. BY THE COURT, a ? Christylee L. Peck, J. ? Lyubov Batazhan 219 Fox Drive Mechanicsburg, PA 17050 ?rn Plaintiff, pro Se r , y c_ W ti SP 4-195 1,1.1-99) FENNSYLVANIA STATE POLICE CENTRAL REPOSITORY 1800 ELMERTON AVENUE I t r `('? HARRISBURG, PA 17110 `NO???" 717-183-3762 :..j2 FJR - L? .. ? ie 2 S P i a 2: 3 v DATE: Monday, Marl-'UMERLAND COUNTY PFNIN S5'E..VfANIA PROTHONOTARY RE: SID: CUMBERLAND CO COURTHOUSE NAME: BATAZHAN i, UBOVN N 1 COURT HOUSE SQUARE SOC: 172-72-4288 CARLISLE, PA. 17013 COURT DOCKET #: 12-1026 In accordance with the Name Change Act of 1998, the fingerprint cards of the above named individual. who has applied for a name change. has been searched in the tiles of the Pennsylvania State Police, Criminal Records and Identification Division Central Repository, and: IX ) This person is not subject to 18 PA C.S. Chapter 91. and the fingerprints have been destroyed. ( )'this person is subject to 18 PA C.S. Chapter 91, and the name change has been noted on the person's criminal history record information. ( ) A criminal record was revealed containing felony convictions. IN ACCORDANCE WITH THE NAME CHANGE ACT, THE COURT SHALL NOTIFY THE PENNSYLVANIA STATE POLICE WHI?N A NAME CHANGE FOR A PERSON CONVICTED OF A FELONY HAS BEEN ORDERED. The Pennsylvania State Police. upon receipt of this notice. shall include the change of name information in the Central Repository as provided for in 18 PA C.S.. Chapter 91 (relating to criminal history record information). ( ) This person has been convicted of felony violation(s) for which the court may not order a change of name. ( j A criminal record was revealed that might prohibit a name change. Because the subsection(s) of the affected conviction(s) has not been provided to us, we are unable to determine whether a name change can or cannot be made. Please provide the subsection(s) of the following crime(s): if available. You are also advised that the above response is based on comparison of fingerprints and associated requester- furnished information against a name index and fingerprints contained in the tiles of the Pennsylvania State Police Central Repository - only - and does not preclude the existence of other criminal records which may be obtained in the repositories ofother local, state, or federal criminal justice agencies. If we may he of any further assistance to you concerning this matter, please contact us at the above address or telephone number. Sincerer Director, Crimin cor s and Identification vision IN THE MATTER OF IN THE COURT OF COMMON PLEAS OF PETITION FOR CHANGE OF CUMBERLAND COUNTY, PENNSYLVANIA NAME OF LYUBOV N. CIVIL ACTION - LAW BATAZHAN NO. 12-1026 CIVIL TERM ORDER OF COURT AND NOW, this 3rd day of April, 2012, upon consideration of the attached Petition for Change of Name, a hearing is scheduled for Thursday, May 24, 2012, at 2:15 p.m., in Courtroom No. 5, Cumberland County Courthouse, Carlisle, Pennsylvania. IT IS FURTHER ORDERED that notice of the filing of said Petition and the aforesaid date, time and place of the hearing be published once in the Cumberland Law Journal and a newspaper of general circulation in the County at least 10 days prior to the hearing; in addition, Petitioners shall comply with all other requirements of C.C.R.P. 5, and the Act of December 16, 1982, P.L. 1309, §6 (see 54 Pa. C.S. §701 [Historical and Statutory Notes] [Main Volume]), and 54 Pa. C.S. §§701 et seq. BY THE COURT, W Christylee . Peck, J. Lyubov Batazhan 219 Fox Drive Mechanicsburg, PA 17050 Petitioner, pro Se : rc d cr e s lY a d'-d 4k1L IN THE MATTER OF: PETITION FOR CHANGE OF NAME OF LYUBOV N. BATAZHAN: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 12-1026 CIVIL TERM IN RE: NAME CHANGE ORDER OF COURT AND NOW, this 24th day of May, 2012, the Petitioner having appeared for a hearing in this matter for name change and having shown proof of publication of the name change in the Patriot-News and the Cumberland Law Journal, and having received documentation from the Prothonotary's office that shows that there is a judgment entered against her from Capital One Bank USA, it is hereby ordered as follows: The Petitioner is directed to notify Capital One Bank USA of the filing of the petition for the name change in writing, by mail, return receipt requested, and that such notice shall contain the following information: That she has filed for the change in her name to include what her former name was and what she desires her name to be changed to, that judgment was entered against her in Cumberland County at docket 2010-06112 in the amount of $16,004.35, and that Capital One Bank USA may file an objection to the name change or any document contesting the name change or may appear at any hearing in this matter to contest the same. If Petitioner files proof of the notice to Capital One Bank USA within 30 days of the date hereof, this matter will then be listed for another hearing when we will take testimony of the Petitioner as to the name change. By the Court, Christyle(? L. Peck, J. Y -tom ?J rA) , m Lyubov Batazhan - 219 Fox Drive Mechanicsburg, PA 17050 ° - 330 1 f h CC)P,Y 1144. -eel 130?ia a p.rLiJ i }j'i IN THE MATTER OF IN THE COURT OF COMMON PLEAS OF PETITION FOR CHANGE OF CUMBERLAND COUNTY, PENNSYLVANIA LYUBOV N. BATAZHAN CIVIL ACTION -LAW NO. 12-1026 CIVIL TERM IN RE: PETITION FOR CHANGE OF NAME ORDER OF COURT AND NOW, this 5~' day of September, 2012, the Defendant having appeared in Court on May 24, 2012, regarding the above petition, and the Court having directed the Petitioner to notify Capital One Bank USA of the filing of the petition for name change in writing, by mail, return receipt requested, and the Petitioner having failed to file any proof of this notice to Capital One Bank USA, it is hereby ordered and directed that the Petition for Change of Name is dismissed, without prejudice to the Petitioner to refile the petition and to comply with the Court's order of May 24, 2012. BY THE COURT, Christyl L. Peck, J. ~~ n /Lyubov Batazhan ~ ~ 219 Fox Drive ..~~- c.'n ors Mechanicsburg, PA 17050 ,E;cv .~ Petitioner, pro Se ~ ~c~ ~~ ~ -~~ , :rc ~ ~ ~ ° Py n~a, lid q'~,i~ ~`