AFFIDAVIT OF INDIGENCY
I hereby affirm that the statements on the attached Petition for Proceeding in
Civil Case without Payment of Fees or Costs are true, complete and correct.
______________________________________
Signature - Petitioner
COMMONWEALTH OF VIRGINIA
COUNTY OF FAIRFAX
Subscribed to, sworn to and acknowledged before me, a Notary Public in and for the
Commonwealth and County aforesaid on this ____ day of ______, 20___.
City/County of_________________
Commonwealth of Virginia
The foregoing instrument was acknowledged before me this ___ day of ___, 20 _____ by
____________________________________
(Name of person seeking acknowledgment)
______________________________________________
Notary Public
Notary registration number:__________________________
My commission expires: ____________________________
CCR Form A-310
August 2009