Motion And Affidavit In Support Of Request To Proceed As A Poor Person
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1IN THE _____ JUDICIAL CIRCUIT COURT, ____________________________, MISSOURI
Judge or Division:
Case Number:
Petitioner:
Petitioner’s Address/Telephone:
VS.
Respondent:
Respondent’s Address/Telephone:
(Date File Stamp)
Motion and Affidavit in Support of Request to Proceed As a Poor Person
Marital Status:
If Married, Spouse’s name:
Number of dependents:
(Include Spouse’s Income and Expenses if Married)
Monthly Income
Monthly Expenses
Gross salary (before deductions)
$ __________________
Mortgage
Rent Payment
$ _______________
Public assistance
$ __________________
Utilities
$ _______________
Retirement/Pension
$ __________________
Food
$ _______________
Social Security
$ __________________
Payment on debts & credit cards
$ _______________
Child Support
$ __________________
Child Support
$ _______________
Maintenance
$ __________________
Maintenance
$ _______________
Other income to be considered
$ __________________
Medical expenses to be considered
$ _______________
__________________________
____________________________
Total Monthly Income
$ __________________
Total Monthly Expenses
$ _______________
Assets
Debts
Cash on Hand
$ ______________
Home loan balance
$ _______________
Bank Accounts:
Automobile loan(s)
$ _______________
Checking
$ ______________
Credit card balance(s)
$ _______________
Savings
$ ______________
Other debts to be considered
Approximate value of home
$ ______________
______________________
$ _______________
And/or other real estate
$ ______________
______________________
$ _______________
Approximate value of automobile(s)
$ ______________
______________________
$ _______________
(1) yr/make ______________
______________________
$ _______________
(2) yr/make ______________
______________________
$ _______________
Approximate value of personal
______________________
$ _______________
Possessions (list)
_________________________
$ ______________
_________________________
$ ______________
_________________________
$ ______________
Total Assets
$ ______________
Total Debts
$ _______________
I swear/affirm under penalty of perjury that these facts are true to my best knowledge and belief.
_________________________________
________________________________________
Date
Your Signature
OSCA (07-15) GN10
1 of 1
Rule 77.03, Section 514.040 RSMo
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