Free Housing Court - Supplement to Indigency Affidavit - Massachusetts

SUPPLEMENT TO INDIGENCY AFFIDAVIT
THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL AND SHALL NOT BE DISCLOSED EXCEPT TO THE PARTIES AND COURT PERSONNEL
NAME: 1. 2. 3. Date of birth: _________________________________________________________________________ Highest grade attained in school: ____________________________________________________ Special training: ______________________________________________________________________

4. Physical or mental disabilities: _______________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 5. Number of dependents: _______________________________________________________________ ____________________________________________________________________________________________ 6. Sources of Income: ____________________________________________________________________ ____________________________________________________________________________________________ 7. Occupation: ___________________________________________________________________________ ____________________________________________________________________________________________ 8. Employer's name and address: ________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 9. Gross annual income from preceding year: $_________________________________________ ____________________________________________________________________________________________ 10. Current Income and expenses: Gross (weekly) (monthly) income $_________________________ Federal tax: __________________________________ State Tax: ____________________________________ Social Security: ______________________________ Health Insurance: __________________________

Pension: _____________________________________ Other: _______________________________________ Total deductions: $____________________________________________

-2-

Net (weekly) (monthly) income: $ _____________________________ Rent: _________________________________________ Food: _________________________________________ Clothing: ______________________________________ Utilities: _______________________________________ Other Expenses: ______________________________ Total expenses: $_______________________________ Net income minus expenses $ ____________________________________ 11. Current Assets and Liabilities:

Assets: Car: ______________________________ Year & Make: _________________________________ Market Value: $_________________________________ Balance due: $__________________________________ Bank Accounts: ___________________________________________________________________________ Other Property: ___________________________________________________________________________ ____________________________________________________________________________________________ LIABILITIES: ____________________________________________________________________________________________ ____________________________________________________________________________________________ 12. Other facts relevant to applicant's ability to pay: ____________________________________________________________________________________________ ____________________________________________________________________________________________ SIGNED UNDER THE PENALTIES OF PERJURY: Signature of applicant: ___________________________________________________________________ Address of applicant: _____________________________________________________________________ Date: _______________________________ Telephone Number: _________________________________