Fill and Sign the Housing Court Supplement to Indigency Affidavit Form

SUPPLEMENT TO INDIGENCY AFFIDAVIT THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL AND SHALL NOT BE DISCLOSED EXCEPT TO THE PARTIES AND COURT PERSONNEL NAME : 1. Date of birth: _________________________________________________________________________ 2. Highest grade attained in school: ____________________________________________________ 3. Special training: ______________________________________________________________________ 4. Physical or mental disabilities: _______________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 5. Number of dependents: _______________________________________________________________ ____________________________________________________________________________________________ 6. Sources of Income: ____________________________________________________________________ ____________________________________________________________________________________________ 7. Occupation: ___________________________________________________________________________ ____________________________________________________________________________________________ 8. Employer’s name and address: ________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 9. Gross annual income from preceding year: $_________________________________________ ____________________________________________________________________________________________ 10. Current Income and expenses: Gross (weekly) (monthly) income $_________________________ Federal tax: __________________________________ State Tax: ____________________________________ Social Security: ______________________________ Health Insurance: __________________________ Pension: _____________________________________ Other: _______________________________________ Total deductions: $____________________________________________ -2- Net (weekly) (monthly) income: $ _____________________________ Rent: _________________________________________ Food: _________________________________________ Clothing: ______________________________________ Utilities: _______________________________________ Other Expenses: ______________________________ Total expenses: $_______________________________ Net income minus expenses $ ____________________________________ 11. Current Assets and Liabilities: Assets: Car: ______________________________ Year & Make: _________________________________ Market Value: $_________________________________ Balance due: $__________________________________ Bank Accounts: ___________________________________________________________________________ Other Property: ___________________________________________________________________________ ____________________________________________________________________________________________ LIABILITIES: ____________________________________________________________________________________________ ____________________________________________________________________________________________ 12. Other facts relevant to applicant’s ability to pay: ____________________________________________________________________________________________ ____________________________________________________________________________________________ SIGNED UNDER THE PENALTIES OF PERJURY: Signature of applicant: ___________________________________________________________________ Address of applicant: _____________________________________________________________________ Date: _______________________________ Telephone Number: _________________________________