Affidavit of Indigency Template

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]

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): ___________________