Filing Waiver.pdf
Ladaysha Truelove Petitioner V · 26-003555-TT
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STATE OF MICHIGAN GRETCHEN WHITMER DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS MARLON I. BROWN, DPA GOVERNOR LANSING DIRECTOR _________________________ Petitioner(s) v 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