Request For Exemption From Payment Of Fees, And Order Page 2

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2.
FAMILY MONTHLY EXPENSES:
Food
Rent
Utilities
Car payments
Furniture & Equipment payments
Child support or alimony
Loans/Time payments
TOTAL EXPENSES:
3.
FAMILY ASSETS (present value):
4.
FAMILY DEBTS:
Cash on hand or
Mortgage
in bank
Loans
Land, bldgs, trailers
Credit cards
Cars
Other (bills, etc.):
Snow machines, boats
airplanes or other
motor vehicles
(except cars)
TOTAL DEBT:
Securities: stocks,
bonds, notes
Businesses
Other Assets:
TOTAL ASSETS:
5.
DEPENDENTS:
Name
Age
Relationship
I swear or affirm that this financial statement is true. I understand that if I give false information
in the financial statement, I may be prosecuted for perjury.
Date
Signature of Plaintiff/Defendant
Subscribed and sworn to or affirmed before me at
, Alaska
on
.
(date)
(SEAL)
Notary Public/Judge/Court Clerk
My Commission Expires:
Page 2 of 3
Adm. R. 9(f)(1), Adm. R. 10;
TF-920 (5/16)(cs)
Adm. R. 12(e)(2); Civil R. 90.3
REQUEST FOR EXEMPTION FROM PAYMENT OF FEES, AND ORDER

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