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Affidavit Of Indigency

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THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4600 | TTY: 617-660-4606 | FAX: 617-660-4613

mass.gov/cjis

AFFIDAVIT OF INDIGENCY

(To Be Submitted with Personal Criminal Record Request)

Subject Name:

Address:

Street and number

City or Town

State and Zip Code

172A, I swear (or affirm) as follows: I AM INDIGENT in that: (check only one of the following)

Pursuant to M.G.L.General Laws, Ch. 6,

I receive public assistance under the following program:

Massachusetts Transitional Aid to Families with Dependent Children (TAFDC)

Federal Supplement Security Income (SSI)

Emergency Aid to Elderly, Disabled and Children (EAEDC)

Medicaid (MassHealth)

Massachusetts Veterans' Programs

My income, less, less taxes deducted from my pay is $____________ per week/month/year (circle period that applies), for

a household of______ persons, consisting of myself and _____ dependents; which income is at or below 125% or less of

the current poverty threshold annually published in the Federal Register by the U.S. Department of Health and Human

Services; [List any other available household income for the circled period on this line: )$_____________] or

I am unable to pay the fees and costs, or I am unable to do so without depriving myself or my dependents of the

necessities of life, including food, shelter and clothing. If you check this box, you must complete the following:

Gross monthly income:

Gross Income for the past twelve months:

If employed, please list your

occupation, employer's name and

address:

If not employed, please list your source

of income:

I am currently incarcerated

(Provide Name & Address of the Correctional Facility in the space below)

I request that the DCJIS waive the fee of $25.00 for a Personal Criminal Offender Record Information (CORI) Request

Signed under the penalties of perjury:

__________________________________________________________________________

Date

Signature of Applicant

ALL INFORMATION CONTAINED HEREIN IS CONFIDENTIAL AND SHALL ONLY BE BE DISCLOSED AS AUTHORIZED BY LAW.

Affidavit Of Indigency

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