Filing Waiver (8).pdf
Mark A Herroscheck Petitioner V Township Of Plainfield Respondent · 26-002682-TT
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_________________________ _____________________________________ ________________________ v STATE OF MICHIGAN GRETCHEN WHITMER DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS MARLON I. BROWN, DPA GOVERNOR DIRECTOR LANSING Petitioner(s) MTT Docket No. _____________ _________________________ Request Date: _________________ Respondent(s) FEE WAIVER REQUEST Instructions: Complete this form and file it with the Tribunal. I request a waiver of filing fees for the following reason (check only one of 1, 2, or 3): 1. ☐ I receive the following type(s) of public assistance because of indigence: ☐Food Assistance Program through the State of Michigan (known as FAP or SNAP) ☐Medicaid (including Healthy Michigan, CHIP, and ESO) ☐Family Independence Program through State of Michigan (known as FIP or TANF) ☐Women, Infants, and Children benefits (WIC) ☐Supplemental Security Income through the federal government (SSI) ☐Other means-tested public assistance ____________________________ 2. ☐ I am represented by a legal services program, or I receive assistance from a law school clinic because of indigence. The name of the legal services program or law school clinic is: ___________________________________ 3. ☐ I am unable to pay the fees and I 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: _________________________________________ I 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. 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, MI 48906 Mark A. & Loujeana R. Herroscheck 7/13/2026 Mark A. Herroscheck, Loujouna R. Herroscheck 7/13/2026