Massachusetts Impaired Driving Program
FEE WAIVER FORM
Office Use Only: Entered ________________ Staff: _______ ASUDS: ___________
This form is to be used only for court-approved 24D program waivers.
COURT OFFICERS: Please complete this form in its entirety.
Print legibly and have this form signed by a presiding justice prior to submission to SSTAR.
FAX THE COMPLETED FORM TO THE MID PROGRAM AT (508) 673-3182
ABOUT FEE WAIVERS FOR CHAPTER 90, SECTION 24D OFFENSES.
Fees that are waived under judicial authority are billed to the Bureau of Substance Addiction Services (BSAS) at the
Massachusetts Department of Public Health (MDPH). As of 1/1/2021 the MID rate is $910.96. This fee is set by the
Massachusetts Rate Setting Commission and is subject to change.
PLEASE INCLUDE THE FOLLOWING INFORMATION ON THIS FORM.
INCOMPLETE FORMS WILL BE RETURNED.
Defendant (Probationer) identity
Amount of fee being waived (this is especially important for partial fee waivers)
Effective date of the waiver
Printed name of approving justice
Signature of approving justice
Court declaration of indigency requires signature of presiding justice below
I, the undersigned, as a duly authorized representative of the court hereby affirm the defendant
(probationer) named herein to be indigent for the purposes of a Chapter 90-24D program fee waiver.
Court Justice (Printed Name)
Court Justice (Si
gnature)
Date Signed
This waiver is approved for the following defendant and conditions noted below
Defendant
’
s Nam
e
Date of Birth
Date of Waiver
Amount Waived
Signatures:
By signing below, I certify that I have read and understand the purpose of this court waiver form. I also understand that
any fees assessed for missed classes are not covered by this waiver and are therefore payable by me.
Defendant
(Printed Name)
Defendant
(Si
gnature)
Date Signed
