Form Ifp102 - Affidavit For Proceeding In Forma Pauperis Page 2
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1
2CONFIDENTIAL
If you did not check #3, 4, or 6 you must answer all of the rest of the questions.
7.
My gross monthly income before taxes and deductions is $
. My net (take home)
monthly income is $
, and the source of that income is:
Job / wages
Unemployment
Spousal Support
Trust Income
Social Security
Other: ________________________________________________________________
8.
My spouse's gross monthly income before taxes and deductions is $
. My spouse's
net (take home) monthly income is $
, and the source of that income is
; OR, I do not know my spouse's income because:
OR
I am not married.
9.
All other family members and dependents living with me have net monthly income as follows:
Name of person
Age
Net (take home) monthly income
Source of that Income
10.
I receive $
per month in child support (includes medical support and/or child
care support.
11.
I pay $_____________ per month in court-ordered child support (
includes medical support and/or
.
child care support)
12.
I pay $
per month in court-ordered spousal support.
13.
I pay $ _____________ per month for
rent
mortgage payment.
14.
I own: Cash
$
Checking, savings and credit union accts
$
Cars, other vehicles (list make, year and equity value (market value minus unpaid loans))
_________________________________
$
_________________________________
$
Real Estate (market value minus unpaid mortgage/loans)
Homestead:
$
Other Real Estate:
$
Other personal property (jewelry, stocks, bonds, etc. - list separately)
_________________________________
$
_________________________________
$
15.
I am presently $____________ in debt, excluding car loans and real estate mortgage/loans.
16.
Other factors which support your request are (explain unusual medical expenses, emergencies, reasons
that the family money is not available to you, or other circumstances to help the Judge understand your
situation):
Dated:
Signature (Sign only in front of notary public or court administrator)
Sworn/affirmed before me this
Name:
day of
,
.
Address:
City/State/Zip:
Notary Public \ Deputy Court Administrator
Telephone: (
)
IFP102
State
ENG
Rev 9/09
Page 2 of 2
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