Supplemental Application For Waiver Or Further Deferral Of Court Fees And Costs Page 3
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STATEMENT OF ASSETS: List only those assets available to you and accessible without financial penalty. Equity is defined as
market value minus any liens or loans.
ESTIMATED VALUE
Cash and bank accounts
$ ________________
Credit union accounts
$ ________________
Equity in:
1. Home
$ ________________
2. Other Property
$ ________________
3. Cars/other vehicles
$ ________________
Other, including stocks, bonds, etc.
$ ________________
Retirement accounts
$ ________________
TOTAL ASSETS:
$ _______________
EXTRAORDINARY EXPENSES: For example, unusual medical needs, financial hardship, costs of care of elderly or disabled
family members. (Proof must be submitted.)
DESCRIPTION
AMOUNT
_____________________________
$ ________________
_____________________________
$ ________________
_____________________________
$ ________________
SIGNATURE UNDER PENALTY OF PERJURY
____________________
__________________________________________________
Date
Signature
__________________________________________________
Print Your Name
11-0120
Revised: 08/15/08
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Parent category: Legal