Fee Waiver Request - Evergreen Class

Fee Waiver Request Form

First Name

Last Name

Date of Request *

Last 4 Digits of SSN *

State of Residence *

Phone Number *

Alternative Phone Number

Attorney Name *

Law Firm or Attorney Code

Attorney Email Address *

Select the course for which you are requesting a fee waiver *A separate Fee Waiver Request must be submitted for each Chapter 13 course.Chapter 7 – Online Pre-Bankruptcy CourseChapter 13 – Online Pre-Bankruptcy CourseChapter 13 – Online After-Bankruptcy Course

Number of Adults in the Household *

Number of Children in the Household *

Total Number of People in the Household

Fee Waiver Eligibility

To qualify for a Fee Waiver, your household income must be less than the amount listed below. Fee Waiver Requests must be submitted and approved before courses are taken.

Household Size	48 Contiguous States and DC, PR, VI, Guam	Alaska	Hawaii
1	$23,475	$29,325	$26,985
2	$31,725	$39,645	$36,480
3	$39,975	$49,965	$45,975
4	$48,225	$60,285	$55,470
5	$56,475	$70,605	$64,965
6	$64,725	$80,925	$74,460
7	$72,975	$91,245	$83,955
8	$81,225	$101,565	$93,450
Each additional person	Add $8,250	Add $10,320	Add $9,495

Required Documents

Please upload the following documents with your Fee Waiver Request:

Last year’s tax return
Paystubs covering your most recent one month

Last Year’s Tax Return *Upload one file in PDF, JPG, JPEG or PNG format.

Drag and Drop (or) Choose Files

Most Recent One Month of Paystubs *Upload up to five files covering your most recent one month.

Drag and Drop (or) Choose Files

Confirmation and Consent *By submitting this form, you acknowledge that your information will be handled according to our Privacy Policy.I confirm that the information provided is accurate, and I consent to submitting these documents to Evergreen Financial Counseling for review of my Fee Waiver Request.

Please do not fill in this field.

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Fee Waiver Request Form

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