Free Financial Affidavit and Application - West Virginia

IN THE _________________ COURT OF ___________________ COUNTY, WEST VIRGINIA

______________________________ v. ___________________________________ Case No. ____________ Defendant or Respondent Plaintiff or Petitioner

FINANCIAL AFFIDAVIT AND APPLICATION: ELIGIBILITY FOR WAIVER OF FEES, COSTS, OR SECURITY IN A CIVIL OR DOMESTIC CASE

A. Information for the Applicant: 1. You will be allowed to file and carry on your civil proceeding without giving security or paying fees or costs that would otherwise be required, if the court finds that you meet the official financial guidelines. 2. You must file a separate affidavit and application anytime your financial situation no longer meets the official guidelines or anytime the court orders you to do so. 3. At any time you may request or the court may require review of your eligibility for a waiver; and at any time the court may require you to pay fees or costs previously waived or to pay future fees or costs. 4. When you sign this form, you will have to swear or affirm that you have completely and truthfully provided all information sought, to the best of your knowledge and ability. If you knowingly give any incomplete and/or false information, you may be prosecuted for the crime of false swearing. 5. The information you give in this form will be confidential only in a domestic violence or a divorce case. 6. Except for signatures, all information must be clearly printed.

================================================================================ B. Information about You and Your Case: 1a. Name: _________________________________ b. Telephone Number: _____________________ c. Address ________________________________ 2. Describe what is involved in your case:__________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

SCA-C&M201.03

(continued)

Financial Affidavit & Application, page 2 of 3

3a. Do you have a lawyer?_______________ b. Have you paid or will you have to pay your lawyer? ________________ c. Will you have to pay your lawyer only if you win? _______________

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C. Information about Your Financial Situation: 1. What is your current yearly household net (take-home) income from all sources (salary or wages, business(es), government payments, rents, pensions, interest, etc.): $ 2a. List the names and relationships to you of all the persons supported by this income, whether or not they are household members:________________________________________________________________________ __________________________________________________________________________________________

b. What is the total number of these persons? 3. How much money do you and your household members have in cash, checking and savings accounts, deposit certificates, and/or bonds (liquid assets)? $ 4a. List your regular monthly household debt-payment and other expenses (mortgage, car, and other debt payments; food, rent, utilities, medical transportation, child-care, and other expenses): ________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ b. What is the total amount of these monthly expenses? $ 5a. List all cars, trucks, motorcycles, or recreational vehicles (all-terrain vehicles, motor homes, snowmobiles, boats), including their make, model, and year, that you and your household members own (collateral assets readily convertible to cash): _________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________

b. What is the total value of these items? $

SCA-C&M201.03

(continued) Financial Affidavit & Application, page 3 of 3

6a. List all real estate (houses, lots, land, rental property, other commercial property) that you or your household members own: _____________________________________________________________________________ ___________________________________________________________________________________________ b. What is the total value of these items? $ ___________________ 7. What would the consequences be for you if a waiver of fees, costs, or security is denied? _________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

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By signing my name on this form, I swear to or affirm: (1) the completeness and truthfulness, to the best of my ability and knowledge, of the information I have provided and (2) my belief that I have a right to a waiver. Signature of Affiant-Applicant:_______________________________________ Taken, subscribed, and sworn or affirmed before me, by the person whose signature appears above, on this ______ day of______________________, in ___________________________ County, West Virginia.

Signature of Notary (Clerk or Deputy Clerk):______________________________________

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For Court Use Only The affiant's application for a waiver is (clerk: initial one) ____________ granted ____________denied. Date:_________________________ Signature of Clerk or Deputy:_______________________________

SCA-C&M201.03