Affidavit Of Indigency Form - South Dakota (Page 3 of 4) in pdf

Affidavit Of Indigency Form - South Dakota Page 3

AUTOMOBILE(S) - make, model, & year:

________________________________________

$_________

HOUSEHOLD GOODS (Furniture, appliances,

TV, stereo, etc.) .......................... $_________

OTHER PERSONAL PROPERTY (Tools, sports

equipment, etc.) ........................... $_________

ANY OTHER ASSETS (Anything else I could

sell or borrow money on) ................... $_________

TOTAL ASSETS ......................... $_________

II.

LIABILITIES (Money that I owe):

REGULAR MONTHLY EXPENSES: (Housing,

utilities, food, etc.) ..................... $_________

LOANS: Amounts owed to:

______________________________________ ..... $_________

TOTAL LIABILITIES .................... $_________

III.

ANTICIPATED INCOME (Money or property

I expect to receive from sale of house or land,

alimony, gifts, inheritances, allotments,

trust funds, lease money, etc.) ................ $_________

Form UJS-305 Rev. 11/2010

Affidavit Of Indigency Form - South Dakota Page 3