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Dispute Resolution Center <br />Of Yakima and Kittitas Counties <br />East '0' Street, suite 4 Yakima WA 98901 <br />HARDSHIP DECLARATION FORM AND FEE REDUCTION APPLICATION <br />Phone Name of Applicant ____________________ _ ----------------------- <br />DRC Case # Fee Amount ----------------------------------------------- <br />DECLARA TION <br />I submit this declaration in support of my request for a fee discount. I certify that the information below is complete and accurate. I <br />have no means to pay the full mediation fee in this action. <br />I declare under penalty of perjury under the laws of the State of Washington that the information I am providing is true and <br />correct, and understand that I may be subject to criminal prosecution if I knowingly provide false information which results in <br />assistance for which I am not eligible. <br />Signedm _________________________________________________ ,on~~----------------------~ <br />(City and State) (Date) <br />(Signature of Applicant) <br />Monthly gross household income, by type: <br />Combined Salary/Wages of all household members* .................. . <br />*Household members include spouses, domestic partners, children, and <br />anyone who contributes to the financial support of the household. <br />Additional Income (ie. rental, capital gains, trusts) ................... . <br />Unemployment Income ......................................... . <br />Child Support Received ......................................... . <br />Financial Aid Income ........................................... . <br />Government Assistance Income ................................... . <br />SSI/Disability Income .......................................... . <br />Other Assistance (i.e. food stamps, etc.) ........................... . <br />Total Household Income ..........................•...........•. <br />How many adults in your household? __ _ How many children in your household? --- <br />Briefly describe your hardship: <br />Plea e e nd the fi.:s't t\vo pages of yo.ur most recent federal lax return (no schedules or worksheet needed) and any <br />related documents that verifY the above numbers. Verification can be pay stubs, food stamp card, letter from a case <br />worker, medical coupon information, bank statements, financial aid letter, unemployment records, etc. We are unable to <br />mail back originals; send copies only. All personal information will be destroyed after use. Applications will be denied if <br />documentation is not supplied. In cases of extreme hardship, an appeal regarding this application may be submitted in <br />writing to the Dispute Resolution Center for special consideration due to extenuating circumstances. <br />DOCUMENT DUE WITHIN TWO WEEKS OF YOUR MEDIATION SESSION DATE BEING CONFIRMED <br />FOR OFFICE USE o Income verification attached? o Tax return attached (last year's)?