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Form 14-0075 - Application To Defer Payment Of Filing Fees, Financial Affidavit And Order Page 2

Current mailing address:_____________________________________________

Current phone number:______________________________________________

Age:________________

Marital status: Single______Married_______Divorced_______Widow(er)_______

Name of spouse:____________________Live with spouse? Yes____No____

If no, length of separation from spouse:_______________________________

Number and ages of

dependents:_______________________________________________________________

INCOME:

Your occupation:_______________________

Are you presently working?

Yes____

No____

If yes: Present Employer:_____________________________

Address:______________________________________

Weekly take-home earnings: $______________

Weekly gross earnings:

$______________

Earned income for past 12 months: $___________

If no: Are you currently receiving weekly workers’

compensation benefits of any kind? Yes____No____

If yes, amount: $_________

Total received in last 12 months: $___________________

Are you currently receiving any other kind of disability income,

such as sick leave, social security disability, or private disability

insurance payments? If so, state amount: $_________per________

Are you receiving child support for any dependents?______________

If so, how much? $______________per____________________.

List all other sources and amounts of income, in your name, name of spouse or jointly shared

with another, including spouse’s salary (net wages), pensions, bonds, stocks, securities,

private business, farming, insurance, retirement benefits, social security benefits, lawsuits or

settlements, gifts or others:______________________________.

Unemployment compensation, heating assistance, food stamps, ADC or welfare relief, in

your name, spouse’s name or jointly shared with another: $_________per __________

List any anticipated tax refunds in the next 6 months and the amount thereof:_______

Whether or not you are presently working, state your income from all sources for the past 12

months: $______________________.

Form 14-0075 - Application To Defer Payment Of Filing Fees, Financial Affidavit And Order Page 2