Affidavit of Indigency Template

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This Affidavit of Indigency (the “Affidavit”) is made on [Date] by:

Affiant: [Full Name], date of birth: [DOB] (optional), address: [Address], phone/email: [Contact].

Court/Case (If Applicable): [Court name], [County/State] | Case No.: [__]

Case Title (Optional): [Plaintiff v. Defendant]

1. Household Information

1.1 Household Size: [__].

1.2 Dependents: [Names/ages/relationship].

1.3 Housing: ☐ Rent ☐ Own ☐ Staying with others ☐ Shelter ☐ Other: [Explain].

2. Employment and Income

2.1 Employment Status: ☐ Employed ☐ Unemployed ☐ Self-employed ☐ Retired ☐ Disabled.

2.2 Employer (If Any): [Name] | Job title: [**].

2.3 Gross Monthly Income: $[**].

2.4 Net Monthly Income: $[__].

2.5 Other Income:

Child support/spousal support received: $[__]/month
Unemployment/disability: $[__]/month
Public assistance (SNAP/TANF/etc.): $[__]/month
Other: [List]

Child support/spousal support received: $[__]/month

Unemployment/disability: $[__]/month

Public assistance (SNAP/TANF/etc.): $[__]/month

Other: [List]

3. Benefits (If Any)

3.1 I receive: ☐ Medicaid ☐ SSI/SSDI ☐ SNAP ☐ TANF ☐ Housing assistance ☐ Other: [List].

3.2 Proof of benefits is: ☐ attached ☐ available upon request.

4. Monthly Expenses

4.1 Housing: $[] | Utilities: $[] | Food: $[] | Transportation: $[].

4.2 Medical: $[] | Childcare: $[] | Insurance: $[**].

4.3 Debt payments: $[] | Other necessary expenses: $[] (list: [**]).

4.4 Total Monthly Expenses (Estimate): $[Total].

5. Assets

5.1 Cash on hand: $[**].

5.2 Bank accounts (total balance): $[**].

5.3 Vehicles: [Year/Make/Model], value $[], loan balance $[].

5.4 Real estate: ☐ none ☐ yes (describe): [], equity $[].

5.5 Other assets (retirement, investments, valuables): [], estimated value $[].

6. Debts

6.1 Credit cards: $[**] total.

6.2 Loans: [Student/auto/personal], total $[**].

6.3 Past-due bills/judgments: $[__].

6.4 Other: [List].

7. Special Circumstances (Optional)

7.1 Explain any special circumstances affecting ability to pay: [Medical condition, recent job loss, etc.].

8. Request and Statement Under Oath

8.1 I respectfully request that the court waive or reduce filing fees and costs due to my financial hardship.

8.2 I declare under penalty of perjury that the information in this Affidavit is true and correct to the best of my knowledge.

Signatures

Affiant: [Full Name]

Date: [Date]

Signature: ___________________________

Witnesses (If Required)

Witness Name: [Name]

Date: [Date]

Signature: ___________________________

Notary / Notarization (If Required)

State of [State]

County of [County]

On [Date], before me, [Notary Name], personally appeared [Affiant Full Name], known to me (or satisfactorily proven) to be the person whose name is subscribed to this Affidavit, and acknowledged that they executed it for the purposes stated.

Notary Public Signature: _______________________

My Commission Expires: _______________________

Notary Seal (if applicable): ___________________

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Affidavit of Indigency Template

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Affidavit of Indigency Template — quick answers

Reviewed July 2026 Free download, PDF & DOCX

What is an affidavit of indigency?

An Affidavit of Indigency is a sworn statement asking a court to waive or reduce filing fees and court costs because you cannot afford them. It typically includes your income, household size, assets, expenses, and any public benefits you receive.

When should you use it?

Use it when filing a court case or responding to one and you need a fee waiver. Some courts require their own official form, so this template is a general version you can adapt and attach to local forms if needed.

What information is usually required?

Courts commonly ask for: household information, employment status, monthly income, public benefits, bank balances, property/vehicles, monthly expenses, debts, and any special circumstances. This template follows that structure.

Do you need supporting documents?

Often yes. You may need pay stubs, benefits letters, bank statements, or tax returns. This template includes a simple checklist of common attachments.

Is it under oath?

Yes. You should be accurate and honest. Providing false information can lead to penalties or denial of the waiver. This template includes a statement under penalty of perjury and a notarization section if required.

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