Civil Cover Sheet Page 15
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222. I reside at (state your full address) ______________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. I have listed my sources and amounts of income truly and correctly on the
attached affidavit.
4. I have the following average monthly expenses for the indicated items:
Housing: __________________
Insurance:
____________________
Utilities: __________________
Transportation: __________________
(Gas):
__________________
Medical:
____________________
(Oil):
__________________
Loans:
____________________
(Electric):__________________
Laundry:
____________________
(Phone): __________________
Child Care:
____________________
Food:
__________________
Child Support: ____________________
Clothing: __________________
5. I neither own nor have equity in any assets other than the following (state values in
dollars): ____________________________________________________________________
___________________________________________________________________________
6. I am unable to pay the costs of these proceedings or to obtain the amount of costs
from family or friends.
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