Form Center

By signing in or creating an account, some fields will auto-populate with your information.

CLERK- Affidavit of Indigence FOIA

  1. Roseville Logo
  2. Affidavit of Indigence-FOIA (Appendix D)

    City Clerk Jennifer A. Zelmanski

    (586) 445-5443

  3. Personal Information
  4. Are you a student?*
  5. Part Time/Full Time*
  6. Marital Status*
  7. Please include Child Support and/or Alimony

  8. Please include Child Support and/or Alimony

  9. Rent/Mortgage, Car Payment, Utilities, Groceries, Installment Payments, etc.

  10. Are you on Public Assistance?*
  11. Are you requesting this Waiver of Fees on behalf of another person who has offered you money to do so?*
  12. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    I further attest that all of the statements made herein are true and correct and that I am considered to be indigent.

  13. Non-Electronic Submittal Instructions

    If you choose to print this application, please mail or hand deliver it to the City Clerk's Office- City of Roseville- 29777 Gratiot Avenue, Roseville, MI  48066.

    License will be issued by the City Clerk if approved.

  14. Leave This Blank:

  15. This field is not part of the form submission.