IN THE COURT OF COUNTY, WEST VIRGINIA Case No. v. Plaintiff or Petitioner Defendant or Respondent FINANCIAL AFFIDAVIT AND APPLICATION: ELIGIBILITY FOR WAIVER OF FEES, COSTS, OR SECURITY IN A CIVIL OR DOMESTIC CASE, OR FOR COSTS ASSOCIATED WITH REQUIRED POLYGRAPH EXAMINATION OR ELECTRONIC MONITORING A. Information for the Applicant: 1. You will be allowed to file and carry on your civil proceeding without giving security or paying fees or costs that would otherwise be required, if the court finds that you meet the official financial guidelines. 2. You must complete the affidavit for the court to determine if the costs of either a polygraph examination, required by W.Va. Code § 62-11D-2, or electronic monitoring, required by W.Va. Code § 62-11D-3, will be paid by the supervising entity. 3. You must file a separate affidavit and application anytime your financial situation no longer meets the official guidelines or anytime the court orders you to do so. 4. You must attach a copy of your most recent salary stub, W-2 form, or other financial documentation (with all Social Security Numbers and all dates of birth removed [you can black them out]) that verifies your income. Without the attached documentation, your application will be incomplete and not considered. 5. At any time you may request or the court may require review of your eligibility for a waiver; and at any time the court may require you to pay fees or costs previously waived or to pay future fees or costs. 6. When you sign this form, you will have to swear or affirm that you have completely and truthfully provided all information sought, to the best of your knowledge and ability. If you knowingly give any incomplete and/or false information, you may be prosecuted for the crime of false swearing. 7. The information you give in this form will be confidential only in a domestic violence or a divorce case. 8. Except for signatures, all information must be clearly printed. B. Information about You and Your Case: 1a. Name: 1c. Address: Page 1 of 3 1b. Telephone Number: SCA-C&M201.03 Rev. 03/2011 Financial Affidavit and Application WVSCA Approved: 03/23/2011 Docket Code(s): MCMWF American LegalNet, Inc. www.FormsWorkFlow.com Case No. 2. Describe what is involved in your case: . 3a. Do you have a lawyer? Yes No Yes Yes No No b. Have you paid or will you have to pay your lawyer? c. Will you have to pay your lawyer only if you win? 4. Check if seeking waiver for: Cost of required polygraph examination (W.Va. Code § 62-11D-2); and/or Cost of required electronic monitoring (W.Va. Code § 62-11D-3). C. Information about Your Financial Situation: 1a. What is your current yearly net (take-home) income from all sources: Employer: $ Public Assistance: $ Benefits: $ Alimony: $ Interest: $ Odd Jobs: $ YEARLY TOTAL: $ Please remember to attach financial documents which verify this information. 1b. If your listed income is zero (0), please explain below and attach some verification (i.e. DHHR or food stamp information): . 2a. List the names and relationships to you of all the persons supported by this income, whether or not they are household members (provided, that these persons can be claimed as dependents on your federal tax return): . 2b. What is the total number of dependents, including yourself ? 3. How much money do you, individually or jointly, have in cash, checking and savings accounts, deposit certificates, and/or bonds (liquid assets)? $ Second Job: $ Food Stamps: $ Disability Benefits: $ Pensions: $ Dividends: $ Other: $ (specify): Self-Employment: $ Unemployment: $ Social Security/SSI: $ Rental Income: $ Annuities: $ SCA-C&M201.03 Rev. 03/2011 Financial Affidavit and Application WVSCA Approved: 03/23/2011 Docket Code(s): MCMWF American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 Case No. 4a. List your regular monthly household debt-payment and other expenses: Mortgage/Rent: $ Credit card payments: $ Cell phone: $ Child Support: $ Other expenses: $ Car payment: $ Other debt payments: $ Food: $ Alimony: $ (specify): Loan payments: $ Utilities: $ Child-care: $ Medical bills: $ 4b. What is the total amount of these monthly expenses? $ 5a. List all cars, trucks, motorcycles, or recreational vehicles (all-terrain vehicles, motor homes, snowmobiles, boats), including their make, model, and year, that you own, individually or jointly: . 5b. What is the total value of these items less any amount owed? $ 6a. List all real estate (houses, lots, land, rental property, other commercial property) that you, individually or jointly, own. . 6b. What is the total value of these items less any amount owed? $ 7. What would the consequences be for you if a waiver of fees, costs, or security is denied? . 8. This application consists of three (3) pages and pages of supporting financial documents. By signing my name on this form, I swear to or affirm: (1) the completeness and truthfulness, to the best of my ability and knowledge, of the information I have provided and (2) my belief that I have a right to a waiver. Signature of Affiant-Applicant: Taken, subscribed, and sworn or affirmed before me, by the person whose signature appears above, on this day of Signature of Notary (Clerk or Deputy Clerk): For Court Use Only The affiant's application for a waiver is (clerk: initial one) Date: Signature of Clerk or Deputy: Page 3 of 3 granted denied. , 20 , in County, West Virginia. SCA-C&M201.03 Rev. 03/2011 Financial Affidavit and Application WVSCA Approved: 03/23/2011 Docket Code(s): MCMWF American LegalNet, Inc. www.FormsWorkFlow.com