Declaration Of Indigency

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NO. _________________________
PETITIONER:
IN THE DISTRICT COURT
JUDICIAL DISTRICT
DEFENDANT:
{COUNTY, STATE}
DECLARATION OF INDIGENCY
I, the
Petitioner
Defendant, do hereby swear under penalty of perjury that I am
indigent and that the following is true and factual to the best of my knowledge:
Name:
DOB:
Email:
Phone:
Address:
Currently Employed?
Yes
No
Income per week: $
Current/Former Employer:
Position:
Spouse:
Employer:
Spouse Weekly Income:
# of Dependents:
Assets/Property:
Monthly Expenses:
I am unable to pay the following court fees:
Bail in the amount of: $
Court-mandated fee in the amount of: $
Attorney Fees
Other:
I am:
Not currently receiving any government entitlement based on indigency.
Currently receiving government entitlement based on indigency in the amount of: $
Signature
Date

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