AFFIDAVIT OF INDIGENCY

IN THE COURT OF

COUNTY OF , STATE OF Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Plaintiff / Petitioner:
vs.
Defendant / Respondent:

Case No:

I. PRELIMINARY STATEMENT

I, , the Affiant herein, being first duly sworn, depose and state that I am the (check one):

in the above-entitled action.

I am submitting this Affidavit to request a waiver of court fees and costs. I am unable to pay the court costs and fees in this matter without substantial hardship to myself or my family. In support of this request, I provide the following financial information under penalty of perjury.

II. PERSONAL INFORMATION

Address:

Phone Number:

Date of Birth:

III. REPRESENTATION

Please select one:

IV. PUBLIC ASSISTANCE / GOVERNMENT BENEFITS

Do you currently receive any of the following forms of public assistance? (Check all that apply)

V. EMPLOYMENT AND INCOME

A. Employment Status

B. Employer Information (if applicable)

C. Monthly Income

Please list all sources of monthly income calculated as a gross monthly average:

1. Wages, Salary, Tips, Commissions: $

2. Self-Employment Income: $

3. Unemployment Benefits: $

4. Social Security / Retirement: $

5. Child Support / Alimony Received: $

6. Disability Benefits: $

7. Investment / Rental Income: $

8. Other Income: $

Total Monthly Income: $

VI. HOUSEHOLD AND DEPENDENTS

1. Marital Status:

3. Number of minor children living in the household:

4. Number of other dependents living in the household:

List the names and ages of all dependents:

VII. MONTHLY EXPENSES

Please list your average monthly expenses:

1. Rent or Mortgage Payment: $

2. Food and Household Supplies: $

3. Utilities (Gas, Electric, Water, Phone): $

4. Transportation (Car payment, gas, bus): $

5. Medical / Dental Insurance & Costs: $

6. Child Care / Child Support Paid: $

7. Credit Card / Loan Payments: $

8. Other Expenses: $

Total Monthly Expenses: $

VIII. ASSETS AND PROPERTY

A. Cash and Accounts

1. Cash on hand: $

2. Checking Account Balance: $

3. Savings Account Balance: $

B. Real Estate

Do you own any real estate (including your home)?

C. Vehicles

Do you own any vehicles?

D. Other Assets

List any other assets of value (stocks, bonds, jewelry, boats, etc.):

IX. DEBTS AND LIABILITIES

Please list any major debts (excluding those listed in monthly expenses above), such as judgments, tax liens, or large medical bills:

X. ADDITIONAL INFORMATION

Please state any other facts regarding your financial situation that you want the Court to consider (e.g., pending eviction, medical emergency, bankruptcy):

XI. OATH AND DECLARATION

I declare under penalty of perjury under the laws of the State of Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming that the foregoing is true and correct. I understand that providing false information in this Affidavit may result in the dismissal of my claims, sanctions, or criminal prosecution.

I further understand that if my financial situation improves during the pendency of this case, I have a duty to notify the Court immediately.

AFFIANT SIGNATURE

Signature: _________________________

Date:

Print Name: _______________