Affidavit Of Indigency And Request For Relief From Fees And Costs
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Affidavit Of Indigency And Request For Relief From Fees And Costs Form. This is a Massachusetts form and can be use in Housing Court Statewide.
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Tags: Affidavit Of Indigency And Request For Relief From Fees And Costs, Massachusetts Statewide, Housing Court
COMMONWEALTH OF MASSACHUSETTS
________________,SS:
HOUSING COURT DEPARTMENT
___________________ DIVISION
No.
____________________________________
Plaintiff
VS.
______________________________________
Defendant
AFFIDAVIT OF INDIGENCY AND REQUEST
FOR RELIEF FROM FEES AND COSTS
The undersigned applicant states for an affidavit under penalties of perjury pursuant
to Gen.L. c. 261, §27A-G as follows:
1. Applicant is indigent in that he/she:
____________ receives PUBLIC ASSISTANCE under the Aid to Families with
Dependent Children (AFDC), General Relief (GR), Veteran’s
Benefits (VA), Supplemental Security Income (SSI), or Medicaid
(MA) programs, (circle which programs), or;
____________ has INCOME, after taxes 125% or less of the current poverty
threshold annually established by the U.S. Office of Management
and Budget, cf. Gen.L. c. 221A, §1, or;
____________ is otherwise unable to pay the fees and costs of the proceeding, or
is unable to do so without deprivation of necessities of life,
including food, shelter and clothing.
2. Applicant requests that the following normal fees and costs (e.g., entry, filing
fees, service of process costs, etc.) be waived, substituted or paid for by the state: ______
____________________________________________________________________________________________
Signed under the penalties of perjury:
____________________________________________
Name:_____________________________________
Address:__________________________________
___________________________________________
DATE: ____________________________________
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