Form #1: Application to Proceed
In Forma Pauperis
Read the form carefully as you fill it out. When
you sign it, you are agreeing to its terms.
Complete the beginning section (called "the caption") as it appears
on your court Complaint form.
Check the boxes for whichever fees you want waived. If you are not sure whether you
will need all of them waived, check them all.
Date and sign the form. Then print your name, address, and telephone number (if
you have one) in the blanks provided.
Leave the bottom part of the page blank below the word "ORDER."
The judge will complete this.
Form #2: Indigency Affidavit
Read and complete the form carefully. When you sign
it, you are swearing to it's truth.
1. Heading
Fill in the district, location and docket number (if you have one) of your court case.
Fill in your name, date of birth, age, phone number and mailing address.
Check the box marked waiver of fees and charges in the following civil case.
Then
fill in the name of your court case (for example,
"Jane Brown v. John Brown").
Check your marital status. Use separated if you are still legally married but
living away from your spouse.
Fill out the line about your education level.
For the line about who you live with, check all the boxes that apply to you. For
example, if you live with your parents and your children, check both boxes.
List the names and ages of your dependents - people who live with
you who depend on you for their support (for example, your children or elderly
parents). State how each person is related to you.
2. Cash Assets
List cash on hand, checking accounts, savings accounts, stocks, savings bonds, and all
other types of accounts with money that is available to you. If you do not have an asset
listed on the form, do not leave it blank; fill in "0" . If your
name is on the account with someone else, write "joint" next to the
amount in the account.
List a total of all your cash assets.
3. Income
Fill in the blanks under Employment . If you are not currently working,
put "I
do not have a job," then answer the other questions.
If you are paid for any other work not covered in the Employment section,
list it in Number 2. This includes income from babysitting, self-employment, etc.
List all your monthly or weekly income in the next section. Do not include the
value of food stamps or rent subsidies.
If you are married, list your spouse's name, address and income information in the next section.
You must also fill this out if you and a roommate share expenses or if you
are under 18 (to include your parent). At part 4.g, write "No"
if none of this person's income is available to you.
Complete Numbers 5 and 6.
4. Other Assets
Fill in this section for the specified assets. Be sure to note whether the property is
jointly owned. Also note whether you owe money on these assets and how much.
If you are not sure of the amounts, write down your best estimate.
5. Expenses
Complete the section on monthly expenses. Be sure to list all of your expenses. If
you spend all of your income each month, or you are constantly in debt, then your total
expenses are at least as much, or more than, your income. Your affidavit should reflect that.
Be sure to include the cost of personal and
household supplies, as well as the cost of school lunches on Line 1.a.
On Line 1.d., list all other regular expenses, including expenses you have
because you work or go to school (for example, child care, transportation,
tools, and uniforms).
Do not include the amount of money you pay each month for loan payments in
Number 1. These go on Line 2.
If you pay alimony, child support or medical expenses for another person, include
these on Line 3. Include any amounts you pay for medical insurance.
Line 4 is where you can list unusual expenses. For example, you may need car
repairs or dental work, or you may owe money such as past due rent. If your only income is
TANF, SSI, or General Assistance, write that in this space. You should get a
fee waiver.
You will be asked to give your Social Security number on a separate, confidential form.
If you haven't already filled out a Social Security Number Confidential Disclosure Form
(#CV-CR-FM-200), you can get
one here. File this with the other two forms.
Finally, you must sign the form in front of a notary public, lawyer, judge or
court clerk. When you do that, you are swearing to its
truth. (Leave the section at the bottom of the page blank; the Court
will fill this out.)
