Affidavit Of Indigency Form - South Dakota Page 4

WHEREFORE, based upon the foregoing statements and allegations, I respectfully request

that the Court enter its Order to waive payment of the filing fee and the fees for service of process

upon the Defendant in this matter, pursuant to SDCL 16-2-29.2. If this Application for Indigent

Waiver of Filing Fee is denied by the judge, you must pay the filing fee in order to proceed with the

case. If the filing fee isn’t paid within 30 days, your case will be dismissed.

Dated this _______ day of __________________, 20___.

_________________________________________

Plaintiff

Name: (Printed) ___________________________

Address: _________________________________

City/State/Zip: ____________________________

Telephone: (_____)_________________________

Subscribed and sworn to before me this _________ day of _______________________,

20___.

_________________________________________

Notary Public/Clerk of Courts

If Notary, my commission expires:

(SEAL)

Form UJS-305 Rev. 11/2010

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