Form Cv-410a - Petition For Waiver Of Fees And Costs - Affidavit Of Indigency (Page 2 of 3) in pdf

Petition for Waiver of Fees and Costs - Affidavit of Indigency and Order

Page 2 of 3

Case No.

Other means-tested public assistance:

Lwm txoj kev pab

My financial situation

has

has not changed since I became eligible for this program.

Kuv txoj kev muaj nyiaj txiag

tau

tsis tau hloov txij kuv tau txais kev pab zaum no.

If you checked the “has” box, and such changes would make you ineligible for the program(s) if you

applied today, you must complete Section 2.

Yog hais tias koj khij lub npov “tau” lawm, thiab qhov kev khij ntawv yuav ua rau koj tsis tsim nyog tau

txais kev pab yog hais tias koj thov tuaj hnub no, koj yuav tsum khij theem 2 kom meej.

Section 2 Theem 2.

1. I

am not

married

Kuv

tau

tsis tau

sib yauv

2. I

am not

employed. Name of employer:

Kuv

tau

tsis tau

ua haujlwm. Qhov chaw haujlwm lub npe:

3. I earn

weekly

every 2 weeks

twice monthly

monthly

]

[Gross pay

Kuv khwv tau [ua ntej txiav se]

lim tiam

2 lub lim tiam

2 zaug ntawm ib hlis

Txhua hli

My take-home pay

is $

per pay period.

[after taxes and deductions]

Kuv nqa los tsev [tom qab txiav se thiab nrho lwm yam] yog $

ib zaug twg.

4. I receive gross monthly income totaling the amount of $

from

Kuv tau txais ua ntej txiav se txhua hli yog $

los ntawm

Pension

Social security

Unemployment compensation

Nyiaj Tso Rau Yav Laus

Nyiaj Laus

Nyiaj Poob Haujlwm

Disability

Student loans/grants

Other:

Nyiaj Muaj Mob

Nyiaj Nqiv Los Kamw Ntawv Lwm yam:

5. I have the following cash assets:

Kuv muaj nyiaj ntsuab raws li nram qab no:

Savings accounts:

Cash:

Nyiaj Tso Tom Tuam Txhab (Savings)

Nyiaj Ntsuab:

Checking accounts:

Money owed me: $

Nyiaj Tso Tom Tuam Txhab (Checking):

Nyiaj Lawv Tseem Tiv Kuv:

6. I have the following other assets:

Kuv muaj lwm yam khoom vaj khoom tsev:

Vehicle-Yr./Make:

Household furnishings: $

Tsheb-Xyoo/Hom:

Rooj Tog:

Vehicle-Yr./Make:

Equity in real estate:

Tsheb-Xyoo/Hom:

Paj Nce Ntawm Koj Lub Tsev:

Other individual assets valued over $200 each:

Lwm yam khoom muaj nqis tshaj li $200:

7. My household consists of myself and

others:

Cov neeg hauv kuv tsev muaj kuv thiab

leej tib neeg:

Full name:

Relationship to me:

Under age 18

Yes

Lub Npe:

Txheeb Kuv Li Cas

Tsis Tau Nto 18 xyoo

Yog

TsisYog

Full name:

Relationship to me:

Under age 18

Yes

Lub Npe:

Txheeb Kuv Li Cas

Tsis Tau Nto 18 xyoo

Yog

TsisYog

Full name:

Relationship to me:

Under age 18

Yes

Lub Npe:

Txheeb Kuv Li Cas

Tsis Tau Nto 18 xyoo

Yog

TsisYog

Full name:

Relationship to me:

Under age 18

Yes

Lub Npe:

Txheeb Kuv Li Cas

Tsis Tau Nto 18 xyoo

Yog

TsisYog

Full name:

Relationship to me:

Under age 18

Yes

Lub Npe:

Txheeb Kuv Li Cas

Tsis Tau Nto 18 xyoo

Yog

TsisYog

CV-410A, 02/16 Petition for Waiver of Fees and Costs - Affidavit of Indigency (Hmong 06/16)

§§757.675(3), 757.69(2m) and 814.29, Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.

Page 2 of 3

Form Cv-410a - Petition For Waiver Of Fees And Costs - Affidavit Of Indigency Page 2

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