AFFIDAVIT OF INDIGENCY COURT OF APPEALS OF GEORGIA _________________________, APPELLANT Vs _________________________, APPELLEE AFFIDAVIT OF INDIGENCY Comes now ________________ (Appellant's name) first being duly sworn, deposes and states I am financially unable to pay the filing fee required for filing in the Court of Appeals of Georgia, and I request that I be permitted to file Appellant's Brief or Appellant's Application without having to pay filing fees. I further swear that the responses which I have made to the questions and instructions below are true. 1. Are you presently employed either full or part time? G Yes G No If the answer is "Yes", state the amount of your salary or wages per month, and give the name, address and phone number of your employer: ________________________________________________________________________ * * * * CASE NUMBER ___________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ If the answer is "No", state the date of last employment and the amount of the salary and wages per month which you received: _______________________________________________ _________________________________________________________________________ _________________________________________________________________________ 2. Have you received within the past twelve months any money from any of the following sources? Business, profession or form of self-employment? Pensions, annuities or life insurance payments? Rent payments, interest or dividends? Gifts or inheritances? State or Federal benefit allowances? Any other sources? G Yes G Yes G Yes G Yes G Yes G Yes G No G No G No G No G No G No American LegalNet, Inc. www.FormsWorkFlow.com If the answer to any of the above is "Yes", describe each source of money and state the amount received from each source during the past twelve months: _______________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ ____________________________________________________________________________ 3. Do you own any cash, or do you have money in a checking or savings account? G Yes G No If the answer is "Yes", state the total value of the items owned: ________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 4. Do you own any real estate, stocks, bonds, notes, automobiles or other property (excluding ordinary household furnishings and clothing)? G Yes G No If the answer is "Yes", describe the property and state its approximate value: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ 5. List the persons who are dependent upon you for financial support, state your relationship to those persons, and indicate how you contribute toward their support:_______________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6. Are you being represented by counsel? If the answer is "Yes", was counsel appointed by the State? G Yes G Yes G No G No If the answer is "Yes", is/was counsel paid by you? G Yes G No If the answer is "No", please explain your ability to pay counsel but not court fees. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 7. Did you apply for pauper or indigency status in the trial court? If the answer is "Yes", did the lower court grant your request? G Yes G Yes G No G No American LegalNet, Inc. www.FormsWorkFlow.com If you were not considered indigent in the lower court, explain why such status should be granted in this Court. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I understand that a false statement or answer to any question in this affidavit will subject me to penalties for perjury and that state law provides as follows: (a) A person to whom a lawful oath or affirmation has been administered commits the offense of perjury when, in a judicial proceeding, he knowingly and willfully makes a false statement material to the issue on point in question. (b) A person convicted of the offense of perjury shall be punished by a fine of not more than $1,000 or by imprisonment for not less than one nor more than ten years, or both. OCGA �1610-70. I, ______________________________, do swear and affirm under penalty of law that the statements contained in this affidavit are true. I further attest that this affidavit is not submitted to harass or to cause unnecessary delay or needlessly increase in the costs of litigation. This the ________day of _______________, ______. __________________________________________ (Your name printed or typed) ___________________________________________ (Sign your name.) ___________________________________________ ___________________________________________ (Your complete address and telephone number) Sworn to and subscribed before me This the ______ day of _______________, ______. _________________________________Notary Public SEAL American LegalNet, Inc. www.FormsWorkFlow.com