Affidavit In Support Of Marion County Indigent Guardianship Fund Application And Or Motion To Waive Fees And Costs Page 2
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28. Does the Respondent currently receive Medicaid or SSI benefits?
Yes
No
9. Is the Respondent currently employed?
Yes
No
SECTION B - TO BE COMPLETED BY APPLICANTS RELATED TO THE RESPONDENT BY BLOOD OR MARRIAGE
1. Your Full Name: _______________________________________Phone:_______________________
2. Address, City, State, Zip: _____________________________________________________________
3. Social Security No. _____________________________________Married:
Yes
No
4. Your relation to the Respondent is: _____________________________________________________
5. Name and address of your spouse or nearest relative:________________________________________
____________________________________________________________________________________
6. Name, address and age of your dependent children and relationship of any other dependents you are
supporting: ___________________________________________________________________________
____________________________________________________________________________________
7. Name and address of current employer: __________________________________________________
________________________________________________________Monthly net pay: ______________
8. Name and address of spouse’s current employer: __________________________________________
________________________________________________________Monthly net pay: ______________
9. List all other sources of income besides employment pay for yourself and your spouse: ____________
____________________________________________________________________________________
10. List balance and name of bank for any bank accounts owned by you or your spouse: _____________
____________________________________________________________________________________
11. List all other property or assets owned by you or your spouse and their value (example - stocks,
bonds, jewelry, furniture, etc): ____________________________________________________________
____________________________________________________________________________________
12. List the amount and name of debtor for money owed to you or your spouse by others: ____________
____________________________________________________________________________________
13. List the nature and amount of your expenses: ____________________________________________
____________________________________________________________________________________
NOTE TO ALL APPLICANTS: Attach a copy of the letter or form from the referring agency
confirming payment authorization.
The above information is true and I ask the Court to use this information to determine whether this
case can be approved for payment from the Marion County Indigent Guardianship Fund and/or waiver of
court fees and costs.
_____________________________________
Signature of Applicant
SUBSCRIBED AND SWORN TO before me this ________ day of _________________, 20______.
______________________________________
Clerk/Notary/Judge
Submitted by:
My Commission Expires: _________________
______________________________________
Name
Bar No. (if any)
_______________________________________
______________________________________
Address
Telephone
_______________________________________
______________________________________
City, State, Zip
E-mail
Fax
AFFIDAVIT IN SUPPORT OF MARION COUNTY INDIGENT GUARDIANSHIP FUND APPLICATION AND/OR
MOT ION TO W AIV E FEE AN D C OS TS - Page 2 of 2
FC (10/20/04)
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