Filing Waiver.pdf

Page 1

STATE OF MICHIGAN 

GRETCHEN WHITMER 

DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS 

MARLON I. BROWN, DPA 

GOVERNOR 

LANSING 

DIRECTOR 

Willie 

 Mocaen 

TE 

Petitioner(s)” 

v 

MTT Docket No. 

Request Date: S-27 ~ 2% 

Respondent(s 

Gi by 

& 

N Deveak 

topery sess an: 

Biacd 

& 

Leven 

FEE WAIVER REQUEST 

Instructions: Complete this form and file it with the Tribunal. 

1 request a waiver of filing fees for the following reason (check only one of 1, 2, or 3): 

1. 

OI receive the following type(s) of public assistance because of indigence: 

x Food Assistance Program through the State of Michigan (known as FAP or SNAP) 

0 Medicaid (including Healthy Michigan, CHIP, and ESO) 

O Family Independence Program through State of Michigan (known as FIP or TANF) 

00 Women, Infants, and Children benefits (WIC) 

J Supplemental Security Income through the federal government (SSI) 

[J Other means-tested public assistance 

2. O1am represented by a legal services program, or 

| receive assistance from a law 

school clinic because of indigence. The name of the legal services program or law 

school clinic is: 

3. Olam unable to pay the fees and 

| did not check item 

1 or 2. 

My gross household income is $ 

every 

(week/two 

weeks/month/year) 

The number of people 

| in my household is 

My source of income is 

List assets and their worth, such as bank accounts. 

If you need more space, attach a 

separate sheet: 

List obligations and how much you pay, such as rent or other debts. 

If you need more 

space, attach a separate sheet: 

| declare under the penalties of perjury that this request has been examined by me and that 

its contents are true to the best of my information, knowledge, and belief. 

gue Mop 

Tre 

S-a1-2y 

Signature 

Date 

MICHIGAN TAX TRIBUNAL 

- 611 W. OTTAWA ST., LANSING, Mi 48933 

- 517-335-9760 

PO BOX 30232, LANSING, MI 48909 

- Other Carriers: 2407 N. GRAND RIVER AVE., LANSING, M1 48906