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

Form Cv-410a - Petition For Waiver Of Fees And Costs - Affidavit Of Indigency Page 3

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

Page 3 of 3

Case No.

8. The other members of my household have gross monthly income totaling the amount of $

from

Cov neeg nrog kuv nyob hauv tsev tau nyiaj txhua hli tag nrho yog $

los ntawm

Wages

Social security

Relief funded under public assistance

Food stamps/FoodShare

Haujlwm

Nyiaj Laus

Nyiaj Pab Dawv los ntawm tsoom fwv

Nyiaj muas noj

Pension

Student loans/grants

Unemployment compensation

Supplemental security income

Nyiaj Tso Rau Yav Laus SNqi nqiv kawm ntawv

Nyiaj poob haujlwm

Nyiaj Laus (SSI)

Disability

Relief funded under §59.53(21), Wisconsin Statutes

Support/maintenance

Nyiaj Xiam

Nyiaj Pab Daws Kev txom Nyem hauv tsab cai §59.53(21), xeev Wisconsin Cov Cai

Nyiaj pab yug menyuam/poj niam/txiv

Other:

Lwm yam:

9. I have the following debts:

Amount:

Monthly Payment:

Kuv muaj cov nqi hauv qab no:

Npaum Cas:

Them Ib Hlis:

a. Mortgage/Rent

Nqi Tsev Yuav/Xaub

b. Auto loan

Nqi Tsheb

c. Credit cards

Nqi Credit Cards

d. Other:

Lwm Yam:

10. I have the following unusual expenses, other than ordinary living expenses

Kuv muaj lwm yam nqi txawv tshaj li ntawm cov nqi, uas niaj hnub siv:

State of

Lub Xeev

I understand that if my financial situation changes,

County of

Lub Zos

I must notify the court immediately

Subscribed and sworn to before me on

Kuv nkag siab zoo hais tias yog kuv txoj kev muaj nyiaj txiag

Thov thiab cog lus tim ntsej muag ntawm kuv

hloov, kuv yuav tsum ceeb toom lub tsev hais plaub paub

kom sai li sai tau

Notary Public/Court Official Tus Neeg Ntaus Thwj, Neeg Hauv Tsev Hais Plaub



Name Printed or Typed Npe Sau lossis Ntaus

Signature Hneev Tes Kos Npe

My commission/term expires:

Kuv muaj cai ntaus thwj/tag kas nuv:

Print or Type Name Sau Npe Los Yog Ntaus

Date of Birth Hnub Yug

Address Chaw Nyob

Phone Number Tus Xov Tooj

Date Hnub Tim

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.

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Form Cv-410a - Petition For Waiver Of Fees And Costs - Affidavit Of Indigency Page 3

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