ARM 23.2.301. AFFIDAVIT OF INDIGENCE AFFIDAVIT OF INDIGENCE AND ORDER

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