Commonwealth of Massachusetts
SUPPLEMENT TO AFFIDAVIT OF INDIGENCY
AND REQUEST FOR WAIVER, SUBSTITUTION OR STATE PAYMENT OF FEES & COSTS
(Note: If you checked (C) on the AFFIDAVIT OF INDIGENCY, you must complete this form.) ______________________________ Court Name of applicant Address (Street and number) (City or town) (State and Zip) __________________________________________________________ Case Name and Number (if known)
Under the provisions of General Laws, Chapter 261, Sections 27A-G, I swear or affirm as follows: 1. PERSONAL INFORMATION (a) (b) (c) (d) Date of Birth: Highest Grade Attained in School: Special Training: List any physical or mental disabilities which you wish to reveal and which affect your earning capacity or living expenses:
(e) 2.
Number of Dependents:
INCOME AFTER TAXES (monthly): (a) If from employment, list your occupation and your employer's name and address:
(b)
Source of income, if not from employment:
(c)
My gross annual income for the past twelve months was:
$
(d) (e)
Gross Income (monthly): Taxes Deducted (monthly): Federal Tax State Tax Social Security Medicare Other Taxes (specify) Total Taxes Deducted $_______________ $_______________ $_______________ $_______________ $_______________
$
$ $
(f) (g)
Total Income After Taxes (subtract 2(e) from 2(d)):
If any other member of your household is employed, list occupation and name and address of his/her employer and monthly income after taxes:___________________________________________________
3.
NET INCOME (monthly): (a) (b) Income After Taxes (from Line 2(f)): Expenses (monthly): Rent or Mortgage Food Electricity Gas Oil Water Telephone Health Insurance Other (specify): $____________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ Uninsured Medical Expenses Child Care Education Expenses for Children Child Support Clothing Laundry/Cleaning Car Insurance Transportation Expenses $____________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ $
$__________________________________
_____________________________________________________ Total Expenses (c) Income After Taxes Minus Expenses (monthly) (subtract 3(b) from 3(a)): $ $
4. (a)
ASSETS Own home? ________________________ Market Value $ _______________________
Balance owed $_______________________ (b) Own Car? ________________________ Year & Make _______________________
Market Value $_______________________ Balance Owed $_______________________ (c) Bank Accounts (specify type and balance)
(d)
Other Property Including Real Estate (specify type and value)
5.
DEBTS (a) Specify:
6.
MISCELLANEOUS (a) Other facts which may be relevant to your ability to pay fees and costs?
Signed under the penalties of perjury: Signature: Type/Printed Name: Address: Date:
By order of the Supreme Judicial Court, all information in this affidavit is CONFIDENTIAL. Except by special order of a court, it shall not be disclosed to anyone other than authorized court personnel, the applicant , applicant's counsel or anyone authorized in writing by the applicant. This form prescribed by the Chief Justice of the SJC pursuant to G.L. c. 261, ยง 27B. Promulgated March , 2003