Fill and Sign the Indigency Waiver Form

IN THE ________________ (Name of Court) COURT OF ___________________ (County), __________________ (State)_________________________ PLAINTIFF(Name of Plaintiff)V. CAUSE NO. ________,_________________________________ DEFENDANT(Name of Defendant)State of County of Affidavit of Indigency Personally appeared before me, the undersigned authority in and for said county and state, ____________________ (Name of Affiant), who, in order to be allowed to proceed in forma pauperis in the above-entitled action in ________________________________________ (Name of Court) , having been being first duty sworn by the undersigned Notary Public, deposes and says:1. I am unable to make prepayment of fees and costs or give security for fees and costs, and it is my belief that I am entitled to redress in the above-entitled action.2. I have not, for the purpose of avoiding payment of costs, divested myself of any property, monies, or any items of value.3. (Set forth brief statement as to nature of above-entitled action). ________________ ______________________________________________________________________ ______________________________________________________________________. 4. My residence address is __________________________________________________ _______________________________ (street address, city, county, state, zip code).5. I am _____________________________________ (single or married or separated or divorced; if married, state full name of spouse).6. I have [no dependents, or, the following dependents: (state names and relationships, and monthly amounts of support contributed for each)] __________ ______________________________________________________________________ ______________________________________________________________________.7. I am [unemployed, and have been unemployed since (date of last employment]. ______________________________________________________________________. or, 7. I am employed, and the name and address of my Employer are as follows: ______________________________________________________________________ ______________________ (Name and address of Employer). I have been employed by said Employer for (e.g., number of months or years) ____________________, with a (e.g., weekly) _________________ salary of $____________. My position with said Employer is (describe) ___________________________________________________ _____________________________, and my duties and responsibilities are (describe) ____________________________________________________________________________________________________________________________________________.8. (If married, set forth employment status and information pertaining to spouse) ______________________________________________________________________ ______________________________________________________________________.9. (State ownership, if any, in real property, describing the property, its location, its estimated value, and the outstanding debt pertaining to it). _________________________________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 10. (Describe personal property, such as automobiles, including its present value and the outstanding debt pertaining to it) _____________________________________ ______________________________________________________________________ ______________________________________________________________________.11. The total amount of cash that I have on hand in accounts in banks, savings accounts, and other financial institutions is $____________. The names and addresses of these financial institutions are as follows: (list) _____________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________.12. The total amount of money that I (and my spouse, if applicable) have invested in retirement accounts is $____________. The names and addresses of the institutions in which these accounts are maintained are as follows: (list) _______________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________.13. In the last 12 months, I ________________ (have/have not) received monies from the sources listed below. (If monies were received from any of sources, set forth amounts and source) __________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________.14. I am indebted to the following creditors, for the amounts indicated: (list names of creditors and amounts owed) ____________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________. Witness my signature this _____________________ (date)._________________________________________ (Name and Signature of Affiant) SWORN to and subscribed before me, this the _____ day of ______________, 20____._____________________________NOTARY PUBLICMy Commission Expires:____________________