Affidavit Of Inability To Pay Court Costs And Ad Litem Fees Form Page 2

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3.
Ward’s Assets (list value)
Home
$ __________________
Mortgage
$ __________________
Trust or Special Needs Trust Fund Corpus
$ __________________
Bank Accounts
$ __________________
Certificates of Deposits
$ __________________
IRAs
$ __________________
401(k)s
$ __________________
Stocks
$ __________________
Bonds
$ __________________
Mutual Funds
$ __________________
Other Investment/Retirement Accounts
$ __________________
Rental Property
$ __________________
Mortgages
$ __________________
Motor Vehicles (cars, trucks, motorcycles, etc.)
$ __________________
Mobile Homes
$ __________________
Other (trailer, boat, camper, guns, collections, etc.)
$ __________________
Oil, Gas, and Mineral properties
$ __________________
Structure Settlements
$ __________________
Real Estate Lien Notes
$ __________________
Other (not listed above)
________________________________________
$ __________________
TOTAL VALUE OF ALL ASSETS
$
4.
Ward’s Monthly Expense
Rent Payment
$ __________________
Car Payment
$ __________________
Transportation Costs
$ __________________
Insurance
$ __________________
Food
$ __________________
Utilities
$ __________________
Medical/Dental
$ __________________
Clothing/Laundry
$ __________________
Expenses not listed above:
$ __________________
Creditor _____________________________________
$ __________________
TOTAL OF ALL MONTHLY EXPENSES
$
“I swear under penalty of perjury that the above information is complete and correct.”
________________________________________
Applicant’s signature
SUBSCRIBED AND SWORN TO BEFORE ME by _________________________________ on this
the _____ day of ___________________________, 20____.
(printed name of Applicant signing the affidavit)
______________________________________
Notary’s signature
Affidavit of Inability to Pay (last updated 1/1/2014)
Page 2
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