Form 4-222. Application for free process and affidavit of indigency.

[For use with Supreme Court General Rule 23-114 NMRA] STATE OF NEW MEXICO COUNTY OF ___________________ ________________________ COURT _______________________________, Petitioner, v. No. ________________ _______________________________, Respondent. APPLICATION FOR FREE PROCESS AND AFFIDAVIT OF INDIGENCY I request that the court enter an order permitting me to file this case without prepayment of fees and costs and give upon my oath or affirmation the following statement. My marital status is: Single ____ Married ____ Divorced ___ Separated ____ Widowed____ I request interpretation services: ___ yes ___no (If yes, please describe what you need) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ INFORMATION ABOUT MY FINANCES (check all that apply to you and fill in the blanks): A. PUBLIC ASSISTANCE ___ I do not receive public assistance (If you check this blank, go directly to Section B EMPLOYMENT/UNEMPLOYMENT). ___ I currently receive the following public assistance in ________________County (please check all applicable public assistance programs): ___Temporary Assistance for Needy Families (TANF) ___Food Stamps ___Medicaid (for myself) ___General Assistance (GA) ___Supplemental Security Income (SSI) ___Public Housing ___Disability Security Income (DSI) ___Department of Health Case Management Services (DHMS) ___Other (please describe _________________________________________) B. EMPLOYMENT/UNEMPLOYMENT ___ I am currently unemployed and have been unemployed for ___ months in the past year. I am unemployed because _________________________________________. ___ I receive unemployment benefits in the amount of $ ___________ per month. ___ I have no income because I am unemployed. ___ I am employed. I am paid $ ______ per hour and work _____ hours per week. My employer’s name, address and phone number is: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___ I am married, and my spouse is unemployed and has been unemployed for ____ months in the past year because ________________________________________________________________________. ___ My spouse receives unemployment benefits in the amount of $ _________ per month. ___ I am married, and my spouse is employed. My spouse is paid $ ______ per hour and works ______ hours per week. My spouse’s employer’s name, address and phone number is: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ C. OTHER SOURCES OF INCOME (check all that apply) ___ I have income from another source not mentioned above. ____ Child Support $ _________ ____ Alimony $ _________ ____ Investments $ _________ ____ Community property from my spouse $ _________ ____ Other _________________________ $ _________ ___ I do not have any other sources of income. ___ I am married, and my spouse has income from another source not mentioned above. ____ Child Support $ _________ ____ Alimony $ _________ ____ Investments $ _________ ____ Other _________________________ $ _________ ____ Other _________________________ $ _________ ___ I am married, and my spouse does not have any other sources of income. ___ Another adult contributes to household income in the following amount: $______ D. OTHER ASSETS (Please list other assets owned by you or your spouse that can be turned into cash. Do not include money you have in retirement accounts): Cash on hand $__________ Bank accounts $__________ Income tax refund $__________ Other assets (describe below): ____________________ $__________ ____________________ $__________ IF YOU DO NOT HAVE ACCESS TO YOUR OWN OR YOUR SPOUSE’S INCOME OR ASSETS, EXPLAIN WHY. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ E. MONTHLY EXPENSES House Payment/Rent $__________ Utilities $__________ Telephone $__________ Groceries (after food stamps) $__________ Car Payment(s) $__________ Gasoline $__________ Insurance $__________ Child Care $__________ Student and Consumer Loans $__________ Court-ordered family support obligations $__________ Other court-ordered payments $__________ Medical expenses $__________ Other____________________ $__________ F. HOUSEHOLD I live at ________________________________________________________________, and the head of the household is _____________________________________________. Other than myself, the other members of the household are: Name Age Employment I Support ____________________ _________ _______________ ( ) ____________________ _________ _______________ ( ) ____________________ _________ _______________ ( ) ____________________ _________ _______________ ( ) ____________________ _________ _______________ ( ) ____________________ _________ _______________ ( ) ____________________ _________ _______________ ( ) This statement is made under oath. I hereby state that the above information regarding my financial condition is correct to the best of my knowledge. I hereby authorize the Court to obtain information from financial institutions, employers, relatives, the federal internal revenue service and other state agencies. If at any time the Court discovers that information in this application for free process was false, misleading, inaccurate, or incomplete at the time the application was submitted, the Court may require me to pay for any costs or fees that were waived under an order of free process that was granted based on the information in this application. ___________________________________ (Signature) ___________________________________ (Print Name) ____Petitioner (Pro Se) ____ Respondent ___________________________________ (Street Address) ___________________________________ (City, State, Zip Code) ___________________________________ (Telephone) State of ____________________________ ) ) ss County of __________________________ ) Signed and sworn to (or affirmed) before me on __________________________________ (date) by ______________________ (name of applicant). ________________________________ Notary My commission expires: ____________ IF YOU ARE REPRESENTED BY AN ATTORNEY, YOUR ATTORNEY MUST SIGN THE FOLLOWING CERTIFICATE. I, ______________________, hereby certify that I have not received any attorney (Name of attorney) fee to represent ____________________. If any attorney fee is paid to me, I understand (Name of applicant) that I shall pay to the court clerk from such attorney fee any court fees and costs that may be waived by the court. ___________________________________ (Attorney signature) ___________________________________ Address ___________________________________ City, State, Zip Code ___________________________________ Telephone/Fax Number