Affidavit For Proceeding In Forma Pauperis Page 2
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1
2
3CONFIDENTIAL
6. My gross annual family income (before taxes and deductions) is $
which
is less than 125% of the Federal Poverty Line for my family size of _________ members.
I have attached proof of my family income or I will provide proof if requested.
7.
My gross monthly income before taxes and deductions is $
. My net (take
, and the source of that income is: Job /
home) monthly income is $
wages
Unemployment
Spousal Support Trust Income
Social Security
Other: _______________________________________________________________
8.
My spouse’s gross monthly income before taxes and deductions is $
.
My
spouse’s net (take home) monthly income is $
, and the source of
that income is
; OR, I do not know my spouse’s income
because:
I am not married.
OR
9.
All other family members and dependents living with me have net monthly income as
follows:
Name of person
Age
Net (take home) monthly income
Source of that Income
10.
I receive $
per month in child support (includes medical support
and/or child care support.
11.
I pay $_____________ per month in court-ordered child support (
includes medical support
.
and/or child care support)
12.
I pay $
per month in court-ordered spousal support.
I pay $_____________ per month for rent mortgage payment.
13.
14.
I own: Cash
$
Checking, savings and credit union accts
$
Cars, other vehicles (list make, year and equity value (market value minus unpaid loans))
_________________________________
$
_________________________________
$
Real Estate (market value minus unpaid mortgage/loans)
Homestead:
$
Other Real Estate:
$
Other personal property (jewelry, stocks, bonds, etc. - list separately)
_________________________________
$
_________________________________
$
IFP102
State
ENG
Rev 02/13
Page 2 of 3
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