Last updated on Feb 20, 2026
WY-CCM-25 free printable template
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IN THE DISTRICT COURT JUDICIAL DISTRICT Civil Action Case No. CONFIDENTIAL Print name of other party AFFIDAVIT OF INDIGENCY AND REQUEST FOR WAIVER OF FILING FEES AND ALL FEES ASSOCIATED THEREWITH THE UNDERSIGNED REQUESTS THE COURT TO WAIVE FILING FEES IN THE ABOVE MATTER. THE UNDERSIGNED FURTHER ADVISES THAT INFORMATION CONTAINED IN THIS AFFIDAVIT IS THE TRUTH THE WHOLE TRUTH AND NOTHING BUT THE TRUTH. STATE OF WYOMING COUNTY OF ss Plaintiff/Petitioner Print name of person filing vs....Defendant/Respondent. I FURTHER AUTHORIZE THE COURT TO VERIFY ALL OR ANY PORTION OF THE FOLLOWING I. PERSONAL/LIVING ARRANGEMENTS/ RESIDENCE My name is I am the Year of Birth Place of Birth Marital Status My spouse s name is I currently reside at How Long Physical Address City State Zip Yrs-Mos a Mailing address if different b I live with spouse friend roommate parents My Home Number is My Work Number is a I may be reached during the day at b You can leave a message for me at c My cell phone...number is Married Separated Affidavit of Indigency and Request for Waiver of Fees July 2014 Page 1 of 4 Unmarried single divorced or widowed I own my home YES or NO If you own your home a I owe on the mortgage. b The monthly mortgage payment is c The house I own could be sold for d I pay lot rent of /mo. If you do not own your home f I pay /mo. rent. g I gave the landlord a damage deposit of Previous Address Street Address How long at previous address Yrs/Mos II. OCCUPATION/EMPLOYMENT/INCOME...SOURCES My occupation/trade is a I am employed by b My monthly GROSS income before deductions tax etc* is c My monthly NET income after deductions is d I am unemployed the last time I worked was e My last place of employment was f If currently unemployed please disclose the amount of your last paycheck g I have the following OTHER sources of income Social Security Workers Comp* TANF Benefits Veteran s Benefits Welfare Child Support Unemployment Other III. ASSETS I and my spouse if married...have the following savings and/or checking accounts NAME OF BANK LAST 4 DIGITS OF ACCOUNT NO. CURRENT BALANCE I own the following vehicles recreational vehicles ATV s motorcycles tractors boats jet skis etc YEAR MAKE / MODEL APPROX. VALUE a My friends or family can give or loan me for the expenses of this action* b I can borrow for the expenses of this action* c I own other real estate other than primary residence worth approximately. d I do do not expect to receive a tax refund on. e I am owed...accounts receivable worth about. f I own machinery or equipment worth approximately. g Estimated value of household furniture and appliances is. h I own clothing and jewelry worth approximately. i I own guns worth approximately. j I own tools worth about. IV. DEBTS/OBLIGATIONS I or my spouse if married have the following credit cards CREDIT CARD/LAST 4 DIGITS OF ACCOUNT MONTHLY PMT. AMOUNT OWING CREDIT LINE PAYABLE TO EST. PMTS* BALANCE I have remaining debt as follows include to whom and the...amount owed PAYABLE TO/ADDRESS/PHONE NUMBER PMTS* V.
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What is WY-CCM-25
WY-CCM-25 is a form used to document the coordination of care management services provided to individuals in a healthcare setting.
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Who needs WY-CCM-25?
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WY-CCM-25 is needed by:
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Healthcare providers
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Care managers
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Patients involved in care coordination
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Insurance companies overseeing care services
Complete Guide to the WY--25 Form on pdfFiller
How to fill out a WY--25 form?
Filling out the WY-CCM-25 form is essential for individuals seeking to establish their eligibility for financial assistance in Wyoming. This document serves to collect necessary personal and financial information, allowing the court to ascertain your situation. The process can be efficiently completed using pdfFiller, which offers interactive tools and features that simplify the experience.
Understanding the WY--25 form
The WY-CCM-25 form is a vital document in Wyoming's legal system. It is primarily used by individuals to declare their financial status when filing for assistance. Understanding who needs to fill it out and the consequences of an incorrect submission is equally important.
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The WY-CCM-25 form allows individuals to apply for financial assistance, ensuring they receive the support they need during legal proceedings.
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Typically, any plaintiff or respondent seeking financial assistance as part of a civil case must complete this form before their court appearance.
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A correctly filled-out form is crucial; errors can delay your case or impact the assistance you may receive.
Essential information required for the WY--25 form
To effectively fill out the WY-CCM-25 form, certain information must be collected beforehand. This includes critical personal and financial details that provide the court with a clear view of your financial situation.
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This includes your name, details about the plaintiff and respondent, ensuring that all necessary parties are identified.
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Information such as the District Court's name and your Civil Action Case Number are essential for the court to track your case.
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Providing income details, property ownership, and monthly expenses helps gauge your eligibility for financial assistance.
Filling out the WY--25 form on pdfFiller
Completing the WY-CCM-25 form is straightforward with pdfFiller. The platform provides a user-friendly experience with step-by-step guidance and interactive features that streamline the process.
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Each section of the form is broken down, allowing users to follow prompts that guide them through the completion process.
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Utilizing pdfFiller's tools, like autofill and data-saving features, enhances the efficiency of filling out the form.
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Before submission, you can review the entire form and make necessary edits to ensure accuracy.
Editing and customizing your WY--25 form
One of the excellent features of using pdfFiller is the ability to edit and customize your WY-CCM-25 form easily to suit your needs.
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Personalize your form by adding specific details and adjusting fields as required.
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pdfFiller allows you to add your electronic signature and the date, making the process quicker.
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You can share your document with others for additional input, utilizing pdfFiller's sharing feature.
Submitting the WY--25 form
Once completed, knowing where to submit your WY-CCM-25 form is vital. Submission locations can vary based on your district, so it's crucial to have the right information.
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Find out which court or legal entity in your area is responsible for receiving this form.
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After submission, expect further communication regarding your financial assistance or the next steps in your legal process.
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Staying proactive by following up can help keep your case on track and support your understanding of any additional requirements.
Resources for assistance with your WY--25 form
If you encounter challenges while filling out your WY-CCM-25 form, a variety of resources are available to assist you.
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Links to local legal assistance programs can provide additional support in understanding your rights and obligations.
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Local court clerks can clarify any procedural questions you may have related to your form.
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The support team at pdfFiller is ready to assist users with technical questions or challenges while filing their forms.
How to fill out the WY-CCM-25
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1.Open the WY-CCM-25 form on pdfFiller.
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2.Review the form layout to familiarize yourself with the required sections.
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3.Start with the patient information section: fill in the patient's name, date of birth, and contact details accurately.
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4.Complete the healthcare provider's details, including name, designation, and practice information.
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5.In the care plan section, clearly outline the goals, interventions, and expected outcomes for the patient.
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6.Include any relevant dates for assessments and follow-up appointments as required.
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7.If applicable, provide details about interdisciplinary team members involved in the care.
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8.After filling in all applicable sections, review the information for accuracy and completeness.
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9.Once you verify all fields are correct, use the 'Save' feature to store your document, or select 'Print' if physical copies are needed.
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