Now comes __________________________ who affirms pursuant to Massachusetts General Law c.261, §27A-G as follows:

1. Affiant is indigent in that his income after taxes is 125% or less of the current poverty threshold annually established by the Community Services Administration pursuant to §625 of the Economic Opportunity Act.
2. Affiant requests that the following normal fees and costs either be waived , substituted or paid for by the state:

Appeals Filing Entry Fee 

3. Applicant requests the following extra fees and costs either be waived substituted or waived by the state:
********* None at this time******
 

Signed under penalties of perjury.
____________________________________
____________________________________
NAME: Pro Se
ADDRESS:_____________________________ 
CITY, STATE:______________________________
DATE: ________________ . 2000