Free Supplement of Affidavit of Indigency - Massachusetts

Commonwealth of Massachusetts

SUPPLEMENT TO AFFIDAVIT OF INDIGENCY
AND REQUEST FOR WAIVER, SUBSTITUTION OR STATE PAYMENT OF FEES & COSTS

(Note: If you checked (C) on the AFFIDAVIT OF INDIGENCY, you must complete this form.) ______________________________ Court Name of applicant Address (Street and number) (City or town) (State and Zip) __________________________________________________________ Case Name and Number (if known)

Under the provisions of General Laws, Chapter 261, Sections 27A-G, I swear or affirm as follows: 1. PERSONAL INFORMATION (a) (b) (c) (d) Date of Birth: Highest Grade Attained in School: Special Training: List any physical or mental disabilities which you wish to reveal and which affect your earning capacity or living expenses:

(e) 2.

Number of Dependents:

INCOME AFTER TAXES (monthly): (a) If from employment, list your occupation and your employer's name and address:

(b)

Source of income, if not from employment:

(c)

My gross annual income for the past twelve months was:

$

(d) (e)

Gross Income (monthly): Taxes Deducted (monthly): Federal Tax State Tax Social Security Medicare Other Taxes (specify) Total Taxes Deducted $_______________ $_______________ $_______________ $_______________ $_______________

$

$ $

(f) (g)

Total Income After Taxes (subtract 2(e) from 2(d)):

If any other member of your household is employed, list occupation and name and address of his/her employer and monthly income after taxes:___________________________________________________

3.

NET INCOME (monthly): (a) (b) Income After Taxes (from Line 2(f)): Expenses (monthly): Rent or Mortgage Food Electricity Gas Oil Water Telephone Health Insurance Other (specify): $____________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ Uninsured Medical Expenses Child Care Education Expenses for Children Child Support Clothing Laundry/Cleaning Car Insurance Transportation Expenses $____________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ $

$__________________________________

_____________________________________________________ Total Expenses (c) Income After Taxes Minus Expenses (monthly) (subtract 3(b) from 3(a)): $ $

4. (a)

ASSETS Own home? ________________________ Market Value $ _______________________

Balance owed $_______________________ (b) Own Car? ________________________ Year & Make _______________________

Market Value $_______________________ Balance Owed $_______________________ (c) Bank Accounts (specify type and balance)

(d)

Other Property Including Real Estate (specify type and value)

5.

DEBTS (a) Specify:

6.

MISCELLANEOUS (a) Other facts which may be relevant to your ability to pay fees and costs?

Signed under the penalties of perjury: Signature: Type/Printed Name: Address: Date:

By order of the Supreme Judicial Court, all information in this affidavit is CONFIDENTIAL. Except by special order of a court, it shall not be disclosed to anyone other than authorized court personnel, the applicant , applicant's counsel or anyone authorized in writing by the applicant. This form prescribed by the Chief Justice of the SJC pursuant to G.L. c. 261, § 27B. Promulgated March , 2003