Fill and Sign the Pauperis Application Form

IN THE COURT OF CITY/COUNTY, STATE OF MONTANA BEFORE , JUSTICE OF THE PEACE/CITY JUDGE *********************************** , ) Applicant ) FINANCIAL DATA FOR ) INFORMA PAUPERIS , ) APPLICATION Address ) ) , ) Case No. Phone Number Offense(s) charged: Age: Defendant is is not in custody. DOB: *********************************** No. of Dependents Date last employed: Employed by: I am / my family is currently receiving on a monthly basis: Salary $ AFDC $ Unemployment $ SSI $ Workers Comp $ Medicaid $ Pension $ Food Stamps $ Child Support $ Retirement $ Other Income $ Spouse’s Income $ Assets: Total Income: $ (LIST TOTAL VALUES) Monthly Debts: Cash on hand or in bank $ (FILL IN AMOUNTS PAID OUT PER MONTH) Wages/Money owed to you $ Rent/Mortgage payment $ Real Estate Utilities $ Real Estate value $ Telephone $ Motor Vehicles Groceries $ Gas for Vehicles $ Sporting Equipment Cable or Satellite $ (guns, boats, motorcycles, etc.) $ Drs., Hospitals $ Personal Property, i.e., Furniture, Courts $ Appliances Attorneys $ Value/personal property $ Credit Cards $ Savings Accounts $ Other Monthly Debts $ Stocks/Bonds/Securities $ Total All Assets $ Total Debts per Month $ I do solemnly swear UNDER PENALTY OF PERJURY that the statements in this application are true, and that I have fully disclosed my assets. I am financially unable to employ an attorney. I understand that I may be required to pay all or a portion of the compensation and expenses incurred by my court appointed counsel if I am convicted of the pending charges and am able to do so. SWORN TO this day of , 20 . Signature of Applicant Judge Notary Public for the State of Montana Residing at My Commission expires