Financial Disclosure or Affidavit of Indigency

For the Court to proceed in Forma Pauperis, affiant must execute this specific affidavit.Download

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FINANCIAL DISCLOSURE / AFFIDAVIT OF INDIGENCY 
TO BE FILED WITH MOTION TO PROCEED IN FORMA PAUPERIS 	
I. PERSONAL INFORMATION 	
Name/Applicant Party Represented (if applicant, enter “same”) D.O.B. 
 
Mailing Address 
 City 
 State 
 ZIP 
      
Case No.  Phone 
(           )    Message Phone (within 48 hours) 
(           ) 	
II.  OTHER PERSONS LIVING IN HOUSEHOLD 	
Name 
1) D.O.B Relationship Name 
3) D.O.B Relationship 
 
2)    
4)   	
III. MONTHLY INCOME/EMPLOYMENT INFORMATION 	
Type of Income  Applicant Spouse (or Parents if 
applicant is a juvenile)  Other Household 
Members Total 
Employment (Gross)     
Unemployment      
Worker’s Comp.      
Pension/Social Security     
Child Support      
Works First/TANF      
Disability      
Other      
Employer’s Name (for all household members) 
 	A. TOTAL INCOME 	 	
$ 	
Employer’s Address 
 Phone 
(        ) 	
IV. ALLOWABLE EXPENSES 	V. TOTAL INCOME 	
Type of Expense  Amount 
Child Support Paid Out  
Child Care (if working only)  
 	Total Income – Allowable Expenses = Adjusted Total Income 	 	
Transportation for Work   
Insurance  	 	A. TOTAL INCOME 	$ 	
Medical/Dental  	-	B. EXPENSES 	$ 	
 	 	
 	
 	C. ADJUSTED TOTAL INCOME 	$  	Medical & Associated Costs 
Of Caring for Infirm Family 
Members  
B. EXPENSES  	$  	
VI. ASSET INFORMATION 	
Type of Asset  Describe / Length of Ownership / Make, Model, Year (where applicable)  Estimated Value 
Real Estate / Home  Price:$                           Date Purchased:                           Amt. Owed:$   
Stocks / Bonds / CD’s    
Automobiles   
Trucks / Boats / Motorcycles    
Other Valuable Property    
Cash on Hand    
Money Owed to Applicant    
Other   
Checking Acct. Balance    
Savings/MM Acct. Balance    
  	D. TOTAL ASSETS 	$

VII. MONTHLY LIABILITIES/OTHER EXPENSES 	VIII. GRAND TOTALS 	
Type of Liability  Amount   
Rent / Mortgage    	 	 	
Food  	C. ADJ. TOTAL INCOME 	  	
Electric  	 	 	
Gas  	D. TOTAL ASSETS 	  	
Fuel    
Telephone  	E. LIABILITIES & OTHER	 	 	 	
Cable  	 	  	
Water / Sewer / Trash   	 	
Credit Cards   
Loans  
Taxes Owed   
Other  
E. LIABILITIES & OTHER EXPENSE 	  	
 	  	
IX. AFFIDAVIT OF INDIGENCY 	
          
  I, _______________________________________________________(affiant)	 being duly sworn, say: 	
          	
  I hereby certify that the information I have provided on this financial disclosure form is true to the best of my 
knowledge. 
  
 
 
 
  	 	
   
 
Affiant’s Signature      Date  	
 
 	 	
 	Notary Public/Individual duly authorized to administer oath: 	 	
 	Subscribed and duly sworn before me according to law, by the above named applicant this  	______	 day of 	
_______________________	, _______	, at _______________________, County of 	___________________________	 
and State of 	
_________________	. 	
 	
               
 
Signature of person administering oath Title  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
Rev. 1/15/09