Fillable Affidavit Of Indigency (Page 2 of 3) in pdf

If the answer to any of the above is “Yes”, describe each source of money and state the amount

received from each source during the past twelve months: _______________________________

______________________________________________________________________________

_____________________________________________________________________________

____________________________________________________________________________

3. Do you own any cash, or do you have money in a checking or savings account?

G Yes

G No

If the answer is “Yes”, state the total value of the items owned: ________________________

___________________________________________________________________________

4. Do you own any real estate, stocks, bonds, notes, automobiles or other property (excluding

G Yes

G No

ordinary household furnishings and clothing)?

If the answer is “Yes”, describe the property and state its approximate value:

______________________________________________________________________________

_____________________________________________________________________________

5. List the persons who are dependent upon you for financial support, state your relationship to

those persons, and indicate how you contribute toward their support:_______________________

______________________________________________________________________________

G Yes

G No

6. Are you being represented by counsel?

G Yes

G No

If the answer is “Yes”, was counsel appointed by the State?

G Yes

G No

If the answer is “Yes”, is/was counsel paid by you?

If the answer is “No”, please explain your ability to pay counsel but not court fees.

______________________________________________________________________________

7. Did you apply for pauper or indigency status in the

G Yes

G No

trial court?

G Yes

G No

If the answer is “Yes”, did the lower court grant your request?

Affidavit Of Indigency Page 2