Poverty Affidavit printable pdf download

Poverty Affidavit

07/01/13

IN THE ________JUDICIAL DISTRICT

DISTRICT COURT OF __________ COUNTY, KANSAS

_____________________,

)

Plaintiff,

)

vs.

)

Case No. ___________

)

____________________,

)

Defendant.

)

POVERTY AFFIDAVIT

Note: Do not use this form if you are currently an inmate in the custody of the secretary of

corrections. You should use the Poverty Affidavit – Inmate form or, if you are filing a motion

under K.S.A. 60-1507, you should use the forms relating to Supreme Court Rule 183.

, am unable to pay a docket fee in this matter

by reason of poverty. Pursuant to K.S.A. 60-2001(b)(2), the following information is provided

in support.

Employment: I am ___ employed; ___ not employed.

My employer is:

_______________________________

My employer’s address is:

_______________________________

Income: I receive income from the following sources (list amount per week):

Employment income (after withholdings):

$____________

Rental income:

$____________

Interest and / or dividends:

$____________

Spousal support and / or child support:

$____________

Retirement, pension, social security:

$____________

Disability, workers compensation:

$____________

Unemployment benefits:

$____________

Poverty Affidavit