Legal Indigency Form

LEGAL INDIGENCY FORM

Applicant Name:    Case Number:
Court:    Date Filed:

RECITALS

WHEREAS, Applicant is a party in the above-captioned matter and seeks a judicial determination of indigency to obtain waiver of filing fees, costs, and related expenses and/or appointment of counsel where authorized; and

WHEREAS, Applicant represents that Applicant lacks sufficient income and assets to pay court fees, transcript costs, or retain counsel without substantial hardship to Applicant or Applicant's dependents; and

WHEREAS, the Court may, upon satisfactory proof, grant relief from fees and costs and take such measures as are authorized by law to protect the interests of a person unable to pay;

NOW, THEREFORE, Applicant submits the following sworn statement, financial disclosures, and request for relief.

1. DEFINITIONS

For purposes of this form: "Applicant" means the individual identified above; "Household" means all persons living in the Applicant's residence whose income or resources are available to the Applicant; "Income" means gross receipts from all sources before deductions.

2. ELIGIBILITY STATEMENT

Applicant declares under penalty of perjury that Applicant is unable to pay the costs associated with this action without depriving Applicant or Applicant's dependents of the necessities of life. Applicant understands that knowingly making a false statement to obtain court relief is punishable by law and may result in denial of relief and other sanctions.

3. FINANCIAL DISCLOSURE — INCOME

4. FINANCIAL DISCLOSURE — ASSETS AND LIABILITIES

5. HOUSEHOLD COMPOSITION

6. PUBLIC BENEFITS

Indicate any public benefits currently received (check all that apply):

SNAP / Food Assistance
SSI or SSDI
TANF
Medicaid
Unemployment Insurance
None of the above

7. RELIEF REQUESTED

Applicant requests that the Court grant one or more of the following forms of relief:

Waiver of filing fees and court costs
Waiver of transcript and record preparation fees
Appointment of counsel pursuant to applicable law
Waiver of service or process fees
Other (specify):

8. AUTHORIZATION TO VERIFY

By signing below, Applicant authorizes the Court, its staff, and other authorized agencies to verify financial information contained herein, including inquiries to employers, financial institutions, benefit agencies, and credit reporting sources. Applicant consents to release of records necessary to evaluate this application.

9. CERTIFICATION

I certify under penalty of perjury under the laws of: that the foregoing is true and correct to the best of my knowledge. I understand that making false statements in this application may subject me to criminal or civil penalties and may constitute grounds for denial of relief.

Applicant further understands that the Court may require supplementation of this form, request supporting documentation, and make such investigation as the Court deems appropriate before ruling on the requested relief.

10. NOTICES; AMENDMENTS; MISCELLANEOUS

Notices relating to this application shall be given to the mailing address provided with the case file. This application may be amended in writing upon a showing of changed financial circumstances. Any waiver granted is limited to the specific relief ordered by the Court and does not otherwise create entitlement to additional relief absent express court order.

GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This form and the Court's consideration thereof are governed by the laws and rules applicable to the court in which the above-captioned matter is pending. This document constitutes the entire sworn statement of Applicant concerning indigency for purposes of the referenced case. If any provision hereof is held invalid, the remainder shall remain in full force and effect.

By signing below, Applicant requests the relief indicated and acknowledges that the information provided may be verified by the Court.

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