Financial Disclosure - Affidavit Of Indigency Form
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2FINANCIAL DISCLOSURE/AFFIDAVIT OF INDIGENCY
I. PERSONAL INFORMATION
Name
Case No.
D.O.B.
Mailing Address
City
State
ZIP
Phone
(
)
Residence (if different from above)
Message Phone (within 48 hours)
(
)
II. OTHER PERSONS LIVING IN HOUSEHOLD
Name
Age
Relationship
Name
Age
Relationship
1)
3)
2)
4)
III. MONTHLY INCOME/EMPLOYMENT INFORMATION
Type of Income
Self
Spouse
Household Members
Total
Employment (Gross)
0.00
Unemployment
0.00
0.00
Worker’s Comp.
Pension
0.00
Social Security
0.00
Child Support
0.00
Works First/TANF
0.00
Disability
0.00
Other
0.00
Other
0.00
Employer’s Name (for all household members)
0.00
SUBTOTAL A
$
Address
Phone
(
)
IV. ALLOWABLE EXPENSES
V. TOTAL INCOME
Type of Expense
Amount
Child Support Paid Out
Child Care (if working only)
Total Monthly Income – Total Allowable Expenses = Total Income
Transportation for Work
$
SUBTOTAL A
0.00
Insurance
-
$
SUBTOTAL B
Medical/Dental
0.00
Medical & Associated Costs
0.00
GRAND TOTAL C
$
Of Caring for Infirm Family
Members
0.00
SUBTOTAL B
$
VI. ASSET INFORMATION
Type of Asset
Describe / Length of Ownership / Make, Model, Year (where applicable)
Estimated Value
Real Estate / Home
Price:$
Date Purchased:
Equity:
Stocks / Bonds / CD’s
Automobiles
Trucks / Boats / Motorcycles
Other Valuable Property
Cash on Hand
Money Owed to Applicant
Other
Checking Acct. (Bank / Acct. #)
Savings Acct. (Bank / Acct. #)
Credit Union (Name / Acct. #)
GRAND TOTAL D
$
0.00
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