COMMONWEALTH OF MASSACHUSETTS ________________,SS: HOUSING COURT DEPARTMENT ___________________ DIVISION No. ____________________________________ Plaintiff VS. ______________________________________ Defendant
AFFIDAVIT OF INDIGENCY AND REQUEST FOR RELIEF FROM FEES AND COSTS
The undersigned applicant states for an affidavit under penalties of perjury pursuant to Gen.L. c. 261, §27A-G as follows: 1. Applicant is indigent in that he/she: ____________ receives PUBLIC ASSISTANCE under the Aid to Families with Dependent Children (AFDC), General Relief (GR), Veteran's Benefits (VA), Supplemental Security Income (SSI), or Medicaid (MA) programs, (circle which programs), or; ____________ has INCOME, after taxes 125% or less of the current poverty threshold annually established by the U.S. Office of Management and Budget, cf. Gen.L. c. 221A, §1, or; ____________ is otherwise unable to pay the fees and costs of the proceeding, or is unable to do so without deprivation of necessities of life, including food, shelter and clothing. 2. Applicant requests that the following normal fees and costs (e.g., entry, filing fees, service of process costs, etc.) be waived, substituted or paid for by the state: ______ ____________________________________________________________________________________________ Signed under the penalties of perjury: ____________________________________________ Name:_____________________________________ Address:__________________________________ ___________________________________________ DATE: ____________________________________