Reduced Mediation Fee Application
Use this form to request a reduction of mediation fees based on your household size, income, and financial hardship.
Applicant Information
Please provide your basic information so we can locate your case.
Applicant Full Name
*
First Name
Last Name
Case Number
*
Household Size
*
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Income Verification
Select your household size and the income range that best describes your total gross household income.
Household Size for Income Guidelines
*
Please Select
Please Select
1
2
3
4
5+
Estimated Total Gross Household Income (annual)
*
Please Select
Please Select
Under $20,000
$20,000 - $39,999
$40,000 - $59,999
$60,000 - $79,999
$80,000+
I certify that the information provided is true and complete to the best of my knowledge.
*
I certify that the information provided is true and complete to the best of my knowledge.
Required Documentation
Indicate which documents you are providing to verify your income and upload copies if available.
Types of Documentation Provided
Pay stubs
Tax returns
Benefit award letters
Bank statements
Other
Upload Income Verification Documents
Upload a File
Drag and drop files here
Choose a file
Cancel
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Statement of Hardship (Optional)
You may provide additional information about your financial situation. This section is optional.
Statement of Hardship
Verified Statement & Signature
Please read the statement below and sign to complete your request.
By signing below, I certify that the information provided in this application is true and complete. I understand that this information will be used to determine my eligibility for reduced mediation fees and that providing false information may result in denial of the fee reduction request.
Applicant Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit Application
Submit Application
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