Fill and Sign the Indigency Form

IN THE ___________COURT OF ____________ (County), _______________ (State) _______________________ PLAINTIFF (Name of Plaintiff) V. CAUSE NO. ______,______ _______________________ DEFENDANT (Name of Defendant) Affidavit of Indigency STATE OF ____________________ COUNTY OF _______________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, ___________________ (Name of Affiant), who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. The undersigned Affiant is the Plaintiff in the above captioned case. 2. Affiant’s full name is _____________________________________________. 3. Affiant’s Address is ____________________________________________. 4. Affiant’s Telephone Number is _________________________________. 5. The Date of Birth of Affiant is _____________________________. 6. The Names and Ages of All Dependents of Affiant are as follows: Name Age Relationship _____________________________ ______ ____________________ _____________________________ ______ ____________________ _____________________________ ______ ____________________ _____________________________ ______ ____________________ 7. Affiant is employed by: ___________________ (Name of Employer) of _______ ________________________________________________________________ (street address, city, state, zip code) . 8. Affiant’s present weekly take-home pay is: $____________. Alternative to 7 and 8 above. 7. Affiant is not employed. 8. Affiant is not employed, but receives or expects to receive money from the following sources: AFDC $____________ per month beginning ____________ (date); SSI $____________ per month beginning ____________ (date); Retirement $____________ per month beginning ____________ (date); Disability $____________ per month beginning ____________ (date); Unemployment $____________ per month beginning ____________ (date); Worker's Compensation $____________ per month beginning ____________ (date); Other $____________ per month beginning ____________ (date). 9. Affiant’s expenses are as follows: Rent/House Payment $____________ per month Groceries $____________ per month Electricity $____________ per month Water $____________ per month Gas $____________ per month Transportation $____________ per month Medical $____________ per month Telephone $____________ per month Other $____________ per month (Cable and/or Pager) 10. The Assets of Affiant are as follows: Automobile $____________ Checking/Savings Account $____________ House $____________ Other $____________ 11. The debts of Affiant are as follows: Amount Owed To Whom $____________ ________________________________________________ $____________ ________________________________________________ $____________ ________________________________________________ $____________ ________________________________________________ $____________ ________________________________________________ Affiant declares under the penalty of perjury that the foregoing answers am true, correct, and complete and that Affiant is financially unable to pay the costs of this action.___________________________________ (Printed Name of Affiant)___________________________________ (Signature of Affiant) SWORN to and subscribed before me, this the ____ day of _____________, 20____. _____________________________ NOTARY PUBLIC My Commission Expires: ___________________