ANSWER ALL QUESTIONS. USE N/A IF NOT APPLICABLE

 

STATE OF MONTANA                        )

                                                                :ss.

County of_____________________)

 

I,_______________________ , being first duly sworn, depose and say: That I have a good cause of action or defense but am unable to pay the costs or get security to secure the cause of action or defense. I request the court or administrative tribunal to waive the costs and approve indigence status.   I declare the following:

 

I. PERSONAL INFORMATION

Name                                                                                                                                             

Address                                                                                                                                         

Telephone                        Birthdate                        Age                  SSN                                    

Employed Yes        No        Self-Employed Yes                       No___ 

Employer's name & address                                                                                                       

                                                                                                                                                        

Month last employed                                              Job                                                               

Single                       Married                      Divorced                     Separated                    

Dependents? Spouse                              Number of children                                               

Spouse's name                                                                                                                        

Spouse's birthdate                    Age                Spouse's SSN                                                  

Spouse's employer & address                                                                                                    

                                                                                                                                                       

Are you sharing expenses with anyone? Yes                      No                             

Explain                                                                                                                                              

                                                                                                                                                           

Are you sharing income with anyone? Yes                          No                                

Explain                                                                                                                                                 

 

II. INCOME

 

Income available:

My wages or salary                $                                                     AFDC $                               

Other wages/salary                $                                        Unemployment $                              

Workers' Comp                      $                                               SSI $                                           

Food Stamps                          $                                               Medicaid $                                

Pension                                   $                                           Retirement $                                 

Child support                          $                                           Other Income $                             

Total Household Income:

Last month $                                                    Previous 12 months $                                        

 

III. ASSETS

 

A.     Motor vehicles? Yes                    No                     How many?                           

      Spouse's motor vehicles                                                                                         

      Is/are vehicle(s) paid for?     Yes                        No                  

      If not, how much do you owe?  $                                                                   Year, make

      and model                                                                                                                           

 

B.     Do you or your spouse own any land or other real estate

      or are you or your spouse buying any? Yes                    No                 

      What is the approximate value?                                                                                         

      How much did you pay for it?                                                     When?                             

      Is it paid for? Yes                   No                   If not, how much do you

      or  your spouse owe?                                                                                                            

 

C.     Checking accounts? Yes                         No                   $                                                 

      Savings accounts? Yes                          No                   $                                                     

      Bank                                                                                                                                      

      Stocks or bonds? Yes                      No                          $                                                

      Wages due but not yet received $                                                                                     

      Money owed to me or my spouse $                                                                                  

      Guns, boats, sporting equipment,

      trailer, camper, or tools $                                                                                                   

      Stereo or TV    $                                                                                                                   

      Furniture & appliances     $                                                                                                   

      Other personal property    $                                                                                               

      Specify:                                                                                                                             

                                                                                                                                                    

IV.   OBLIGATIONS/DEBTS

 

Do you or your spouse have any outstanding debts or obligations: (specify and list amount) :

                                                                                                                                                                 

                                                                                                                                                                 

                                                                                                                                                                 

 

I further declare that I am the person named above, that I have read the foregoing questions and information and know the same to be true of my own knowledge, AND THAT IF ANY PART OF THE ABOVE IS MADE FALSELY I AM SUBJECT TO PROSECUTION FOR PERJURY.

 

                                     Signature of Requestor                                                                                        

SUBSCRIBED AND SWORN TO before me this ______________ day of ______________________, 19___.

 

 

____________________________

Notary Public for the State of Montana

Residing at ____________, Montana

My Commission expires _________.

 

ORDER

 

 

Indigence status is hereby denied/granted.

 

DATED:   _____________________________

 

 ______________________________________

                                                                                               Judge/Administrative Officer