Fillable Affidavit Of Indigency - Commonwealth Of Massachusetts printable pdf download

Affidavit Of Indigency - Commonwealth Of Massachusetts

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Commonwealth of Massachusetts

AFFIDAVIT OF INDIGENCY

AND REQUEST FOR WAIVER, SUBSTITUTION

OR STATE PAYMENT OF FEES & COSTS

(Note: If you are currently confined in a prison or jail and are not seeking immediate release under G.L. c. 248 §1, but

you are suing correctional staff and wish to request court payment of “normal” fees (for initial filing and service), do not

use this form. Obtain separate forms from the clerk.)

Court

Case Name and Number (if known)

Name of applicant:

Address:

(Street and number)

(City or town)

(State and Zip)

SECTION 1 :

Under the provisions of General Laws, Chapter 261, Sections 27A-27G, I swear (or affirm) as follows:

I AM INDIGENT in that (check only one ):

(A) I receive public assistance under (check form of public assistance received):

Medicaid (MassHealth)

Transitional Aid to Families with Dependent Children (TAFDC)

Supplemental Security Income (SSI)

Emergency Aid to Elderly, Disabled or Children (EAEDC)

Massachusetts Veterans Benefits Programs; or

(B) My income, less taxes deducted from my pay, is $

week

biweekly

month

year

per

persons, consisting of myself and

(check the period that applies) for a household of

dependents;

which income is at or below the court system's poverty level; (Note: The court system's poverty levels for households

of various sizes must be posted in this courthouse. If you cannot find it, ask the clerk or check online at:

The court system’s poverty level is updated each year.)

); or

(List any other available household income for the checked period on this line: $

or my dependents of the necessities of life, including food, shelter and clothing.

IF YOU CHECKED (C), YOU MUST ALSO COMPLETE THE SUPPLEMENT TO THE AFFIDAVIT OF

INDIGENCY.

Affidavit Of Indigency - Commonwealth Of Massachusetts

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