☐ CIRCUIT COURT ☐ DISTRICT COURT OF MARYLAND FOR
Located at Telephone
Case No.
IN THE MATTER OF: vs.
REQUEST FOR FINAL WAIVER OF OPEN COSTS
Unless you are filing into a restricted case type (Adoption, Emergency Evaluation, Extreme Risk
Protective Order (ERPO), Guardianship, Juvenile, Gender Declaration), you must file a Notice
Regarding Restricted Information Pursuant to Rule 20-201.1 (form MDJ-008) with this submission.
I, , request that the court grant a final waiver of open costs.
I am unable to pay the final open court fees and costs in this matter because of poverty.
Affidavit of Continuing Eligibility
☐ This court waived the prepaid costs in this matter; and:
☐ There has been no material change in my financial situation since the waiver of prepaid costs was
granted.
Affidavit of Income. (Complete this section only if the section above does not apply to you)
I respectfully submit that:
1. There are family members living in my household, including myself.
(Do not include renters or temporary guests).
2. The total gross household income (before taxes) is $
(total income earned by all persons in the household) per ☐ WEEK ☐ MONTH ☐ YEAR.
3. The gross household income (before taxes) is from the following sources
(list amounts before taxes) per ☐ WEEK ☐ MONTH ☐ YEAR:
☐ Wages .................................................................................................... $
☐ Commissions/Bonuses .......................................................................... $
☐ Social Security/SSI ................................................................................ $
☐ Retirement Income ................................................................................ $
☐ Unemployment Insurance ...................................................................... $
☐ Temporary Cash Assistance ................................................................... $
☐ Alimony/Spousal Support ...................................................................... $
☐ Rent received from tenants .................................................................... $
☐ Any Other Income (Do not include food stamps/SNAP) ....................... $
4. I own the following property.
(Do not list your home, one vehicle, and/or personal items in your home):
☐ NONE
☐ Real estate other than principal home .......................................... Value: $
☐ Other vehicles including boats .................................................... Value: $
☐ Bank accounts .......................................................................... Balance: $
☐ Stocks or other securities ............................................................ Value: $
☐ Other property (describe): _____________________________ Value: $
CC-DC-090 (Rev. 08/2024) Page 1 of 3 RWFOC
Name of party
Number
Petitioner/Plaintiff
Respondent/Defendant
City/County
Court Address
This form contains Restricted Information.
Attorney Number
E-mail
City, State, Zip
Attorney Signature
Date
Date
Attorney Name
City, State, Zip
Address
Case No.
5. I owe the following debts:
☐ NONE
☐ Credit Card: Amount Owed: $ Monthly Payment: $
☐ Car Loan: Amount Owed: $ Monthly Payment: $
☐ Other Debt: Amount Owed: $ Monthly Payment: $
6. Other information to demonstrate my inability to prepay the costs:
For these reasons, I request a final waiver of open costs.
I solemnly affirm under the penalties of perjury that the contents of this document are true to the best
of my knowledge, information, and belief.
CERTIFICATE OF SERVICE
I certify that I served a copy of this Request for Final Waiver of Open Costs, upon the following party or
parties by ☐ mailing first-class mail, postage prepaid ☐ hand delivery, on to:
CC-DC-090 (Rev. 08/2024) Page 2 of 3 RWFOC
Fax
Telephone
Fax
Telephone
E-mail
Name
Address
Name
Address
City, State, Zip
City, State, Zip
Date
Signature of Party Serving
Date
☐ CIRCUIT COURT ☐ DISTRICT COURT OF MARYLAND FOR
Located at Telephone
Case No.
IN THE MATTER OF: vs.
ORDER REGARDING REQUEST FOR FINAL WAIVER OF OPEN COSTS
Upon consideration of the Request for Final Waiver of Costs submitted by
, and any further documentation as required or authorized by
Rule 1-325 or other applicable law,
THE COURT FINDS THAT:
The party named above:
☐ Meets the financial eligibility guidelines of the Maryland Legal Services Corporation.
☐ Does NOT meet the financial eligibility guidelines.
The party named above:
☐ Is unable by reason of poverty to pay the costs.
☐ Is NOT unable by reason of poverty to pay the costs.
☐ Other findings:
THE COURT ORDERS that the waiver is:
☐ GRANTED
☐ DENIED
CC-DC-090 (Rev. 08/2024) Page 3 of 3 RWFOC
Date
Judge
ID Number
Name of party
Petitioner/Plaintiff
Respondent/Defendant
City/County
Court Address
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