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Form 14-0075 - Application To Defer Payment Of Filing Fees, Financial Affidavit And Order Page 4

Motor vehicles: Give make, year, present value, amount owing thereon, if any, and whether

registered or titled in your name, name of spouse or jointly with another of all vehicles in which you

have an ownership interest:

Vehicle 1: Description_______________________________

Value $____________ Emcumbrance: $_________________

Lienholder: _____________________

Address: _______________________

Vehicle 2: Description________________________________

Value $ ___________ Encumbrance $ __________________

Lienholder: ______________________

Address: ________________________

Other assets in your name, in the name of your spouse, or jointly owned with someone else, including

furniture, appliances, televisions, stereos, videotape equipment, photographic cameras, jewelry, furs,

trust funds, notes, bonds, stocks, savings certificates, securities, cash value of life insurance,

equipment or machines, boats, aircraft, motorcycles, campers or recreational vehicles, coin or stamp

or any other collections with a recognized market value, livestock, purebred animals, harvested or

unharvested crops, etc. and value of each:

________________________________________________________________________________

Are you a beneficiary or heir in the estate of a person deceased?

Yes___

No___

Does anyone owe you money or have any property belonging to you? If so, give details in

full:___________________________________-

___________________________________________________

Do you have a judgment against anyone? If yes, give name, date, court and amount:

________________________________________________________________________________

EXPENSES:

Average monthly living expense:

Food: $________________per___________

Housing: $_____________per___________

Utilities/telephone: $____________per__________

Clothing: $____________per____________

Transportation: $_______________per__________

Medical (paid by you): $_________per__________

Installment payments: $_________per__________

Payable to:___________________________

$__________per___________

Other: $__________________________________________

Form 14-0075 - Application To Defer Payment Of Filing Fees, Financial Affidavit And Order Page 4