Affidavit Of Indigency Form - South Dakota (Page 2 of 4) in pdf

Affidavit Of Indigency Form - South Dakota Page 2

STATE OF SOUTH DAKOTA )

IN CIRCUIT COURT

:SS

COUNTY OF _______________)

________ JUDICIAL CIRCUIT

_________________________,

DIV _______

Plaintiff,

vs.

AFFIDAVIT OF INDIGENCY

_________________________,

Defendant

Comes now the Plaintiff named above, and after first being duly sworn on oath states and

alleges as follows:

I am the Plaintiff named above; and I make this affidavit pursuant to and in

accordance with SDCL 16-2-29.2 and 16-2-29.3 for the purposes of supporting my request to waive

the filing fee in my action for divorce.

I do solemnly swear that I am unable to pay the filing fee and the service of

process fee of the legal proceedings which I am about to commence for the following reasons; and

that I verily believe I am justly entitled to the relief sought by such legal proceedings.

I am (check one): ______ Employed ______ Unemployed

___ Self-employed.

If employed, my weekly take-home pay is $_____________.

Retirement, disability, or insurance benefits: $____________ per ____________.

Total income before deductions for 20____ was $____________ (prior).

Total income before deductions for 20____ is $____________ (current).

Including myself, I have the following number of dependents: __________.

The following amounts accurately represent my assets and liabilities:

ASSETS (Things I own or am buying):

CASH (on hand or in banks) ................. $_________

ACCOUNTS AND NOTES RECEIVABLE

(IOUs and other money payable to me) ....... $_________

INVESTMENTS (Stock, bonds, savings

bonds, etc.) ............................... $_________

REAL ESTATE (Houses, land, tribal lease

land, real property, etc.) ................. $_________

Form UJS-305 Rev. 11/2010

Affidavit Of Indigency Form - South Dakota Page 2