IN THE DISTRICT COURT OF

DOUGLAS COUNTY, KANSAS

Sarah Marie Hemmerling, )
)
Plaintiff, )
)
vs. ) Case No.
)
Jason Ryan Hemmerling, )
)
Defendant. )

POVERTY AFFIDAVIT OF Sarah Marie Hemmerling

Note: Do not use this form if you are currently an inmate in the custody of the secretary of corrections.
You should use the Poverty Affidavit – Inmate form or, if you are filing a motion under K.S.A. 60-1507,
you should use the forms relating to Supreme Court Rule 183.

I, Sarah Marie Hemmerling, am unable to pay a docket fee in this matter by reason of
poverty. Pursuant to K.S.A. 60-2001(b)(2), the following information is provided in support.

Employment: I Am Not Employed.

Income: I receive income from the following sources (list amount per week):
Employment income (after withholdings): $ 0.00
Rental income: $ 0.00
Interest and / or dividends: $ 0.00
Spousal support and / or child support: $ 0.00
Retirement, pension, social security: $ 0.00
Disability, workers compensation: $ 0.00
Unemployment benefits: $ 0.00
Other Income $ 0.00
Describe:
TOTAL weekly income from all sources: $ 0.00

Assets on Hand: I presently have the following assets (list value):

Cash (including bank accounts and electronic accounts): $ 0
Automobile, truck or other vehicle: $ 0
Real property (home, building or land): $ 0
Other assets (jewelry, watches, etc.) $ 0

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Other Assets: Are you a beneficiary of any current estate, trust, annuity, or life insurance policy?
If so, please provide the details.

Other Reasons: Explain any other facts or reasons why you cannot afford to pay a docket fee in
your case.
I have been unemployed since Feburary 2019. I am currently trying to receive SSI/SSDI.

I, Sarah Marie Hemmerling, declare under penalty of perjury that the information set
forth in this affidavit is true and correct and that, by reason of my poverty, I am unable to pay the
docket fee.

Signed on: ________________

Date

________________________________
Signature of Plaintiff

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 IN THE DISTRICT COURT OF
DOUGLAS COUNTY, KANSAS
Sarah Marie Hemmerling, )
)
Plaintiff, )
)
vs. ) Case No.
)
Jason Ryan Hemmerling, )
)
Defendant. )

Order Regarding Waiver of Filing Fee

Now on this _______ day of __________, 20___, comes this Petitioner seeking a
waiver of docketing fees in this matter. Having reviewed the affidavit of the Petitioner and
other information provided, the Court finds as follows:

____ All waivable filing fees in this matter are waived.

____ The Court will allow the filing of this matter without payment of the filing fees,
but the Petitioner must pay all filing fees at the time the Decree of Divorce is filed.
____ The Court will allow the filing of this matter without payment of the filing fees.
The Court will determine at the time of final hearing on this matter if either party is able to
pay the filing fees associated with this case.
____ The Court finds that the financial situation of the Petitioner has not been
proven or is not sufficiently low to warrant the granting of this request and will Not waive
any filing fees.
It is so ordered.

_____________________________
Judge