Financial Verification Form

Do You Need Help With The Cost?

CourtOrderedProgram.com is happy to aid indigent parents with discounted classes. Complete the form and one of our CourtOrderedProgram.com moderators will review and validate your information. Once qualified, you will receive an email with a promotion code, which will allow you to register for any one class at a pre-determined cost.

Personal Details

Name

Phone

Filing State

Filing County

No filing location? Select county and state of current residence

Classes

Include the name of the class(es) as they appear on your court order or what you believe is required. Include the hours/section/weeks if stated.

Class type

None

Mandated Class

Optional Class

I don't know

Proof of indigent status

You may use: proof your case filing fees were waived, you meet state poverty guidelines, you are receiving foodstamps, medicare/medicaid or other public aid.

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Special Circumstances

If you have additional information that may be helpful in determining your eligibility, let us know.

I understand that terms and conditions may apply

Verification Requirement

Waivers

In forma pauperis, or proof of indigence signed by the court within last 12 months of a signed and dated request from court staff or professional stating financial need.

Qualifying Government Aid:

Name/reference of aid available may vary from state to state.

Food Stamps (SNAP Food Benefits)
Welfare or Temporary Assistance for Needy Families (TANF)
Medical Coverage - Medicaid and Children's Health Insurance Program (CHIP)

(WIC, LIEAP, SSI, Children's Health Insurance Program (CHIP), Medicare, child care assistance, unemployment, free lunch program, Head Start, cash aid, and housing assistance will not qualify unless you meet poverty guidelines)

*All qualifying benefits must be current and court documents must be within the calendar year*

PERSONS IN FAMILY/HOUSEHOLD	POVERTY GUIDELINE
1	$14,840
2	$20,020
3	$25,200
4	$30,380
5	$35,560
6	$40,740
7	$45,920
8	$51,120

For families/households with more than 8 persons, add $5,200 for each additional person.

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