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Form 14-0075 - Application To Defer Payment Of Filing Fees, Financial Affidavit And Order Page 3

ASSETS:

Bank with:____________________________Address:____________________________

Balance personal bank accounts (checking and savings):

$_____________

Balance accounts in name of spouse: $________________

Balance joint accounts with spouse: $_________________

Balance joint accounts with any other person: $_________

List the amount of cash currently in your possession or available to you, including cash on

your person, at your place of residence, in safety deposit boxes, or in any other location:

$________________________________

Real Estate:

Property 1: Type (residence, farm, etc): __________________

Address or location: __________________________

Market value: ________________________________

Insured value:________________________________

Insured with: _____________________________

Address:__________________________________

Tax value:___________________________________

When purchased: ____________________________

Purchase price: ______________________________

Present owners besides yourself:

___________

____________________________________________

Amount of mortgages or liens on property:

______________________________

Is this a homestead? Yes ____ No ____

Property 2: Type (residence, farm, etc.): __________________

Address or location: _________________________

Market value: _______________________________

Insured value:_______________________________

Insured with:___________________________

Address:_______________________________

Tax Value:__________________________________

When purchased:____________________________

Purchase price:______________________________

Present owners besides yourself: _____________

____________________________________________

Amount of mortgages or liens on property:

__________________________________

Is this a homestead? Yes ____ No ____

If more than two properties are owned, list others on a separate sheet and attach to

this form. Is such a sheet attached? Yes_____ No____

Form 14-0075 - Application To Defer Payment Of Filing Fees, Financial Affidavit And Order Page 3