Free IN THE DISTRICT COURT - Wyoming

Name of Person Filing: Address: City, State, Zip Code: Telephone Number: STATE OF WYOMING COUNTY OF ________________ ) ) ss ) IN THE DISTRICT COURT _______________ JUDICIAL DISTRICT Civil Action Case No. _________________

Petitioner:___________________________,) (Print name of person filing) ) ) vs. ) ) Respondent:_________________________, ) (Print name) )

AFFIDAVIT OF INDIGENCY AND REQUEST FOR WAIVER OF FILING FEES AND ALL FEES ASSOCIATED THEREWITH

The applicant is entitled to and requests the court provide access to this State's judicial processes without payment of court fees, pursuant to Boddie v. Connecticut, 401 U.S. 371 (1971) (recognizing that in divorce proceedings, States must provide access to the courts without regard to a party's ability to pay court fees). Furthermore, pursuant to Wyo. Stat. §18-6-608, the court may waive the Sheriff's service fees upon an adequate showing of indigency.

THE UNDERSIGNED REQUESTS THE COURT TO WAIVE FILING FEES IN THE ABOVE MATTER. THE UNDERSIGNED FURTHER ADVISES THAT INFORMATION CONTAINED IN THIS AFFIDAVIT IS THE TRUTH, THE WHOLE TRUTH, AND NOTHING BUT THE TRUTH. I FURTHER AUTHORIZE THE COURT TO VERIFY ALL OR ANY PORTION OF THE FOLLOWING INFORMATION: I. PERSONAL/LIVING ARRANGEMENTS/ RESIDENCE
1. My name is: I am the Petitioner / Respondent [circle one] in the above matter. Date of Birth: ______________________________ Place of Birth: Marital Status: Married Separated Unmarried (single, divorced or widowed)

2. 3.

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4. 5.

My spouse's name is: I currently reside at: ___________________, ___________, ______, _______ How Long? _______ (Physical Address) (City) (State) (Zip) (Yrs-Mos) (a) If mailing address is different, please complete: _______________________________________ (b) I live with: spouse friend roommate parents My Home Number is: (_____) _______________ My Work Number is: (______) ______________ (a) I may be reached during the day at: (_____) _____________ (b) You can leave a message for me at: (_____) _____________ (c) My cell phone number is: (______) ____________ I own my home: YES or NO

6.

7.

If you own your home, then answer: (a) I owe $_____________ on the mortgage. (b) The monthly mortgage payment is: $_____________ (c) The house I own could be sold for $______________ (d) I pay lot rent of $_________/mo. If you do not own your home, then answer: (e) I live with: (f) I pay $____________________/mo. rent. (g) I gave the landlord a damage deposit of $ (h) I pay lot rent of $__________________/mo. 8. Previous Address: ________________________, ________________, _______, _______ (Street Address) (City) (State) (Zip) How long at previous address? ______________ (Yrs/Mos)

9.

II. OCCUPATION/EMPLOYMENT/INCOME SOURCES:
10. My occupation/trade is: (a) I am employed by: (b) My monthly GROSS income (before deductions, tax, etc.) is: $ (c) My monthly NET income (after deductions) is: $ (d) I am unemployed, the last time I worked was: (e) My last place of employment was: (f) If currently unemployed, please disclose the amount of your last paycheck: $ (g) I have the following OTHER sources of income: Social Security $_________________ Workers' Comp. $_________________ TANF Benefits $_________________ Veteran's Benefits $_________________

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Welfare Child Support Unemployment Other

$_________________ $_________________ $_________________ Wks/Mos Remaining:________ $_________________

III. ASSETS:
11. 12. I have the following cash, or other liquid assets, on hand: $ I and my spouse (if married) have the following savings and/or check accounts: NAME OF BANK ACCOUNT NO. CURRENT BALANCE

13.

I own the following vehicles, recreational vehicles, ATV's, motorcycles, tractors, boats, jet skis, etc: YEAR MAKE / MODEL APPROX. VALUE

14.

(a) My friends or family can give or loan me $____________ for the expenses of this action. (b) I can borrow $______________ for the expenses of this action. (c) I own other real estate (other than primary residence) worth approximately $___________. (d) I do do not expect to receive a $___________ tax refund on ____________. (e) I am owed accounts receivable worth about $______________. (f) I own machinery or equipment worth approximately $____________. (g) Estimated value of household furniture and appliances is $____________. (h) I own clothing and jewelry worth approximately $_____________. (i) I own guns worth approximately $______________. (j) I own tools worth about $______________.

IV. DEBTS/OBLIGATIONS:
15. I, or my spouse, (if married) have the following credit cards: CREDIT CARD/ACCOUNT # MONTHLY PMT. AMOUNT OWING CREDIT LINE

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16.

I have the following monthly payments (including utilities, i.e. telephone, cable, etc.): PAYABLE TO MONTHLY BALANCE EST. PMTS. OWING

17.

I have remaining debt, as follows: (include to whom and the amount owed) PAYABLE TO/ADDRESS/PHONE NUMBER MONTHLY PMTS.

BALANCE OWING

V. OTHER:
18. 1) 2) 3) 19. The dependents I claim on my annual income tax returns are: NAME RELATIONSHIP NAME 4) 5) 6) RELATIONSHIP

I have read, am familiar with, and understand the following law of the State of Wyoming: "A person commits a felony punishable by imprisonment for not more than two (2) years, a fine of not more than two thousand dollars ($2,000), or both, if, while under a lawfully administered oath or affirmation in a matter where an oath is authorized by law, he knowingly makes a false certificate, affidavit, acknowledgment, declaration or statement other than in a judicial or administrative proceeding." Wyoming Statute § 6-5-303. _________________________________________ Person requesting waiver of fees (signature required) Print name:

STATE OF WYOMING COUNTY OF ________

) ) )

Subscribed and sworn to before me by ___________________________________ this _______ day of ____________________________, 20____. ________________________________________ Notary Public / Court Clerk My Commission Expires: __________________
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