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Signing a Contract

Application for
Reduced Fees

PLEASE NOTE: This is only shared internally with required members of our team. We follow strict confidentiality practices to ensure your data is safe. 

Please select the types of income YOU receive
Please select the types of income received by ANYONE ELSE in your household

Include a copy of ONE of the following (current within the past 6 months) for each household member with income:

· Your last two pay stubs

· Last years W-2 form (do not send tax return)

· Child support order (with worksheet)

· Financial declaration (filed with the clerk)

· DSHS award letter (with income noted)

· Unemployment benefits notice

If no income verification is attached, you will not be considered eligible for a reduction in fees.

By signing below I certify that all the above information is true and correct, and that all the income and State

assistance information is reported completely and accurately.  I understand that this information is confidential and will be available only to the office staff of Community Mediation Center to determine eligibility for an adjustment to my mediation fee and not shared with any other person or entity.

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