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This document is a fee waiver request form for DebtorCC, Inc. It requests personal and financial information to determine eligibility for a fee waiver, including name, social security number, household size, monthly income, assets, and signature. Instructions require completion of all fields and submission of proof of income. The form has two pages, with the second page detailing various asset categories and a total asset value field. It certifies the accuracy of the information provided and notes a determination will be made within 72 hours via email.
This document is a fee waiver request form for DebtorCC, Inc. It requests personal and financial information to determine eligibility for a fee waiver, including name, social security number, household size, monthly income, assets, and signature. Instructions require completion of all fields and submission of proof of income. The form has two pages, with the second page detailing various asset categories and a total asset value field. It certifies the accuracy of the information provided and notes a determination will be made within 72 hours via email.
This document is a fee waiver request form for DebtorCC, Inc. It requests personal and financial information to determine eligibility for a fee waiver, including name, social security number, household size, monthly income, assets, and signature. Instructions require completion of all fields and submission of proof of income. The form has two pages, with the second page detailing various asset categories and a total asset value field. It certifies the accuracy of the information provided and notes a determination will be made within 72 hours via email.
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
(PAGE
2
of
2)
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.
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.