001

 DEBTORCC,  INC.  -­‐  FEE  WAIVER  REQUEST  

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Return  this  form  and  attachments  by  email  to:  feewaiver@debtorcc.org  
 
Be  sure  to  follow  the  instructions  below:  
 
1. DO  NOT  LEAVE  ANY  FIELDS  BLANK.  
2. Attach  proof  of  income  with  this  form  (2  recent  paystubs,  proof  of  
unemployment/disability,  social  security  award  letter,  income  tax  returns  
for  previous  year,  W2s,  or  earnings  statements  from  the  military).  
 
PERSONAL  INFORMATION  
 
First  Name:  _________________________________________  
 
Last  Name:  __________________________________________  
 
Last  4  of  SSN:  ______________________  
 
Spouse’s  First  Name  (if  joint):  __________________________________________  
 
Spouse’s  Last  Name  (if  joint):  __________________________________________  
 
Spouse’s  Last  4  of  SSN  (if  joint):  ______________________  
 
HOUSEHOLD  SIZE  &  INCOME  
 
Total  Household  Size  (including  you,  your  spouse  and  dependents):  __________________  
 
Total  Monthly  Income  Before  Taxes  or  Other  Deductions  
(including  income  from  you,  your  spouse  and  any  dependents  that  reside  in  your  
household):  $________________________  
 
ATTORNEY/LEGAL  SERVICE  
 
Is  an  attorney  or  legal  service  assisting  you  with  your  case?  
 
☐ YES        
Please  list  the  amount  you  paid  to  your  attorney/legal  service  $________________            
 
☐ NO  
 
 
 
 001  DEBTORCC,  INC.  -­‐  FEE  WAIVER  REQUEST  
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ASSETS  
 
Please  list  an  estimated  value  of  your  assets  below.  
 
Category             Monetary  Value  
 
Cash               $_______________________________  
Savings  &  Checking  Account         $_______________________________  
Money  Market  Accounts         $_______________________________  
Bank  Certificates  of  Deposit         $_______________________________  
Retirement  Accounts           $_______________________________  
Bonds               $_______________________________  
Tax  Refund             $_______________________________  
Stocks               $_______________________________  
Cash  Value  Insurance  Policies       $_______________________________  
Cars/Motorcycles           $_______________________________  
Real  Estate             $_______________________________  
Furniture  and  Appliances         $_______________________________    
Personal  Items  (clothing,  furs,  etc.)       $_______________________________  
Bicycles,  Skis,  etc.           $_______________________________  
Recreational  Vehicles  (boats,  Rv’s,  etc.)     $_______________________________    
Valuables  (Jewelry,  tools,  art,  etc.)       $_______________________________  
Other  Assets             $_______________________________    
 
Total               $_______________________________    
 
I  hereby  certify  that  the  information  provided  in  this  Fee  Waiver  Request  Form  is  
true  and  accurate.  
 
Today’s  Date:  __________________________________________  
 
Signature:  __________________________________________  
 
Spouse’s  Signature  (if  joint):  __________________________________________  
 
We  will  make  a  determination  of  your  fee-­‐waiver  eligibility  within  72  hours  and  
send  you  an  email.  Please  DO  NOT  submit  this  form  more  than  once  as  it  will  delay  
the  process.