Fill and Sign the Undersigned Requests the Court to Waive Filing Fees in Form

Affidavit of Indigency and Request for Waiver of Fees July 2014 Page 1 of 4 STATE OF WYOMING ) IN THE DISTRICT COURT ) ss COUNTY OF ________________ ) _______________ JUDICIAL DISTRICT Plaintiff/Petitioner: , ) Civil Ac tion Case No. ___________ (Print name of person filing) ) ) vs. ) CONFIDENTIAL ) Defendant/Respondent: ______________________ . ) (Print name of other party) AFFIDAVIT OF INDIGENCY AND REQUEST FOR WAIVER OF FILING FEES AND ALL FEES ASSOCIATED THEREWITH THE UNDERSIGNED REQUESTS THE COURT TO WAIVE FILING FEES IN THE ABOVE MATTER. THE UNDERSIGNED FURTHER ADVISES THAT INFORMATION CONTAINED IN THIS AFFIDAVIT IS THE TRUTH, THE WHOLE TRUTH, AND NOTHING BUT THE TRUTH. I FURTHER AUTHORIZE THE COURT TO VERIFY ALL OR ANY PORTION OF THE FOLL OWING INFORMATION: I. PERSONAL/LIVING ARRANGEMENTS/ RESIDENCE 1. My name is: I am the Plaintiff/Petitioner Defendant/Respondent in the above matter. 2. Year of Birth: ______________________________ Place of B irth: 3. Marital Status: Married Separated Unmarried (single, divorced or widowed) 4. My spouse’s name is: 5. I currently reside at: ___________________, ___________, ______, _______ How Long? _______ (Physical Address) (City) (State) (Zip) (Yrs -Mos) (a) Mailing address (if different): (b) I live with: spouse friend roommate parents 6. My Home Number is: (_____) _______________ My Work Number is: (______) ______________ (a) I may be reached during the day at: (_____) _____________ (b) You can leave a message for me at: (_____) _____________ (c) My cell phone number is: (______) ____________ Affidavit of Indigency and Request for Waiver of Fees July 2014 Page 2 of 4 7. I own my home: YES or NO If you own your home : (a) I owe $_____________ on the mortgage. (b) The monthly mortgage payment is: $_____________ (c) The house I own could be sold for $______________ (d) I pay lot rent of $_________/mo. If you do not own your home : (e) I live with: (f) I pay $____________________/mo . rent. (g) I gave the landlord a damage deposit of $ (h) I pay lot rent of $__________________/mo. 8. Previous Address: _____________________________, ________________, _______, _______ (Street Address) (City) (State) (Zip) 9. How long at previous address ? ______________ (Yrs/Mos) II. OCCUPATION/EMPLOYMENT/INCOME SOURCES: 10. My occupation/trade is: (a) I am employed by: (b) My monthly GROSS income (before deductions, tax, etc.) is: $ (c) My monthly NET income (after deductions) is: $ (d) I am unemployed, the last time I worked was: (e) My last place of employment was: (f) If currently unemployed, please disclose the a mount of your last paycheck: $ (g) I have the following OTHER sources of income: Social Security $_________________ Workers’ Comp. $_________________ TANF Benefits $_________________ Veteran’s Bene fits $_________________ Welfare $_________________ Child Support $_________________ Unemployment $_________________ Wks/Mos Remaining:________ Other $_________________ III. ASSETS: 11. I have the following cash, or other liquid assets, on hand: $ 12. I and my spouse (if married) have the following savings and/or check ing accounts: Affidavit of Indigency and Request for Waiver of Fees July 2014 Page 3 of 4 NAME OF BANK LAST 4 DIGITS OF ACCOUNT NO. CURRENT BALANCE 13. I own the following vehicles, recreational vehicles, ATV’s, motorcycles, tractors, boats, jet skis, etc: YEAR MAKE / MODEL APPROX. VALUE 14. (a) My friends or family can give or loan me $____________ for the expenses of this act ion. (b) I can borrow $______________ for the expenses of this action. (c) I own other real estate (other than primary residence) worth approximately $___________. (d) I do do not expect to receive a $________ ___ tax refund on ____________. (e) I am owed accounts receivable worth about $______________. (f) I own machinery or equipment worth approximately $____________. (g) Estimated value of household furniture and appliances is $____________. (h) I own clothing and jewelry worth approximately $_____________. (i) I own guns worth approximately $______________. (j) I own tools worth about $______________. IV. DEBTS/OBLIGATIONS: 15. I, or my spouse, (if married) have the following credit cards : CREDIT CARD/ LAST 4 DIGITS OF ACCOUNT # MONTHLY PMT. AMOUNT OWING CREDIT LINE 16. I have the following monthly payments (including utilities, i.e. telephone, cable, etc.): PAYABLE TO MONTHLY EST. PMTS. BALANCE OWING Affidavit of Indigency and Request for Waiver of Fees July 2014 Page 4 of 4 17. I have remaining debt, as follows: (include to whom and the amount owed) PAYABLE TO/ADDRESS/PHONE NUMBER MONTHLY PMTS. BALANCE OWING V. OTHER: 18. The dependents I claim on my annual income tax returns are: NAME (Initials Only) RELATIONSHIP NAME (Initials Only) RELATIONSHIP 1) 4) 2) 5) 3) 6) 19. I have read, am familiar with, and understand the following law of the State of Wyoming: “A person commits a felony punishable by imprisonment for not mor e than two (2) years, a fine of not more than two thousand dollars ($2,000), or both, if, while under a lawfully administered oath or affirmation in a matter where an oath is authorized by law, he knowingly makes a false certificate, affidavit, acknowledgm ent, declaration or statement other than in a judicial or administrative proceeding.” Wyoming Statute § 6 -5-303. Signature Printed Name: Address: Phone Number: STATE OF WYOMING ) ) COUNTY OF ________ ) Subscrib ed and sworn to before me by ___________________________________ this _______ day of ____________________________, 20 ____ . WITNESS my hand and official seal. ________________________________________ Notarial Officer My Commission Expire s: ______________