Form Coa - Financial Statement Affidavit
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IN THE COURT OF APPEALS
(for court system use)
OF THE STATE OF ALASKA
FINANCIAL STATEMENT AFFIDAVIT
For use with a motion to waive filing fee, when the basis for
the motion is inability to pay, a motion to appeal at public
expense, or an application for an exemption from filing fee
under AS 9.19.010.
1. Appellant’s (or Petitioner’s) Name:
2. Appellant’s Telephone:
3. Case No.
4. Appellant’s Residence Address: ___________________________________________________________
_____________________________________________________________________________________
5. Appellant’s Mailing Address: _____________________________________________________________
_____________________________________________________________________________________
6. a. GMarried GSingle GDivorced GSeparated GWidowed
b. How long?
7. a. Are your working now? GYes GNo
b. If not, date last worked:
8. LIST ALL EMPLOYERS FOR THE LAST 12 MONTHS
a. 1) Present or Former Employer:_____________________________________________________________
2) Address & Telephone:__________________________________________________________________
3) Job Title:_______________________________________ 4) Salary: $__________________per_______
5) FROM__________________ TO ___________________ 5) No. Hours Per Week__________________
(Month and Year)
(Month and Year)
b. 1) Present or Past Employer:_______________________________________________________________
2) Address & Telephone:__________________________________________________________________
3) Job Title:_______________________________________ 4) Salary: $__________________per_______
5) FROM__________________ TO ___________________ 5) No. Hours Per Week__________________
(Month and Year)
(Month and Year)
GNo GYes b. Union:
9. a. Do you belong to a Labor Union?
10. Social Security Number: _____________________(Not mandatory; SSN may be used to identify assets.)
11. a. Spouse’s Name:_____________________________________________________________________
b. Spouse’s Present or PastEmployer:_____________________________________________________
c. FROM________________ TO __________________ d. Salary: $__________________________
12. DEPENDENTS:
1)Name
2)Age
3)Relationship
a. __________________________________________ _____________ ________________________
b. __________________________________________ _____________ ________________________
c. __________________________________________ _____________ ________________________
d. __________________________________________ _____________ ________________________
e. __________________________________________ _____________ ________________________
f. __________________________________________ _____________ ________________________
g. __________________________________________ _____________ ________________________
h. __________________________________________ _____________ ________________________
COA Financial Statement Affidavit-1 (Rev. 1/98)
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