State of Minnesota
Judicial District: Court File Number: Case Type:
Affidavit for Proceeding In Forma Pauperis (Minn. Stat. § 563.01)
) ) SS )
STATE OF MINNESOTA COUNTY OF
(County where Affidavit signed)
I am a party in this action. I am a natural person (not a corporation, partnership or other entity). In good faith, I request a court order waiving court fees and costs. I cannot support my family and myself and also pay or give security for costs. I believe that I have valid reasons for pursuing this action. My pleadings (the Petition, Complaint, Answer, Appeal or other pleading) are attached. I am receiving public assistance under one or more of the following means-tested programs: SSI and/or MSA (The Supplemental Security Income and Minnesota Supplemental Assistance Programs); MFIP (Minnesota Family Investment Program); Food Stamps; General Assistance or Discretionary Work Program; Medical Assistance or General Assistance Medical Assistance; Energy Assistance; I am receiving public assistance under some other means-tested program: (Name the program)
2. 3. a.
I have attached proof that I receive public assistance (such as MFIP card or cancelled check from agency) or I will provide proof if the Judge asks for proof. If you checked #3a. and receive help under one of the listed programs, skip to the signature line on page 2. If you checked #3b. and receive some "Other" means-tested assistance, go to Question 4. 4. I am represented by attorney on behalf of a civil legal services program or volunteer attorney program, based on indigency. If you checked #4, skip to the signature line on page 2.
My family size is ___________. (Include yourself, your spouse, your minor children, and other dependents in your household.) For my family size, I counted myself and (list all others): Name Age Relationship to you
Page 1 of 2
My gross annual family income (before taxes and deductions) is $ which is less than 125% of the Federal Poverty Line for my family size of _________ members. If you checked #6, skip to the signature line on page 2.
If you did not check #3a, 4, or 6 you must answer all of the rest of the questions. 7. My gross monthly income before taxes and deductions is $ . My net (take home) monthly income is $ , and the source of that income is: Job Unemployment Child Support or Spousal Support Public Assistance Trust Income SSI Other: ________________________________________________________________ 8. My spouses' gross monthly income before taxes and deductions is $ . My spouses' net (take home) monthly income is $ , and the source of that income is ; OR, I do not know my spouses' income because: OR I am not married.
9. All other family members and dependents living with me have net monthly income as follows: Name of person Age Net (take home) monthly income Source of that Income
10. 11. 12.
I pay $_____________ per month in court-ordered child support and/or court-ordered child care. I pay $
per month in court-ordered spousal support. rent mortgage payment.
Cash $ Checking, savings and credit union accts $ Cars, other vehicles (list make, year and equity value (market value minus unpaid loans)) _________________________________ $ _________________________________ $ Real Estate (market value minus unpaid mortgage/loans) Homestead: $ Other Real Estate: $ Other personal property (jewelry, stocks, bonds, etc. - list separately) _________________________________ $ _________________________________ $
I pay $_____________ per month for
I am presently $____________ in debt, excluding car loans and real estate mortgage/loans.
Other factors which support my request are (explain unusual medical expenses, emergencies, reasons that the family money is not available to you, or other circumstances to help the Judge understand your situation):
Dated: Signature (Sign only in front of notary public or court administrator)
Subscribed and sworn to before me this day of , . Name: Address: City/State/Zip: Notary Public \ Deputy Court Administrator Telephone:
Page 2 of 2