Form Cv-410a - Petition For Waiver Of Fees And Costs - Affidavit Of Indigency Page 3
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3Petition for Waiver of Fees and Costs - Affidavit of Indigency and Order
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Case No.
Other:
Otro:
9. I have the following debts:
Amount:
Monthly Payment:
Tengo las siguientes deudas
Monto
Pago mensual
a. Mortgage/Rent
$
Alquiler
Hipoteca/
b. Auto loan
$
Préstamo de automóvil
c. Credit cards
$
Tarjetas de crédito
d. Other:
$
Otra:
10. I have the following unusual expenses, other than ordinary living expenses:
Tengo los siguientes gastos extraordinarios, aparte de los gastos normales de subsistencia:
I understand that if my financial situation changes,
I must notify the court immediately.
Entiendo que debo notificar de inmediato al tribunal si mi
State of
situación económica cambia
E
stato de
County of
Condado de
Signature Firma
Subscribed and sworn to before me on
Suscrito y jurado ante mi
Print or Type Name Escriba su nombre en letra de molde o a máquina
Notary Public/Court Official Notario Público/ Funcionario del tribunal
Date of Birth Fecha de nacimiento
Name Printed or Typed Nombre en letra de molde o escrito a máquina
Address Dirección
My commission/term expires:
Mi matrícula/mandato rige hasta:
Phone Number Teléfono
Date Fecha
CV-410A, 02/16 Petition for Waiver of Fees and Costs - Affidavit of Indigency (Spanish 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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