IN THE SUPERIOR COURT OF FULTON COUNTY STATE OF GEORGIA ) ) ) ) ) ) ) ) ___________________________________________, Petitioner, v. ___________________________________________, Respondent. Civil Action File No.: ________________________________ AFFIDAVIT OF INDIGENCY ______________________________, the Petitioner in the above styled _________________ _________________________________________(name of petition), being duly sworn, and says: 1. That I, by reason of my poverty, am unable to pay the costs required by O.C.G.A. § 15-6-77 to file a civil case in the Superior Court of Fulton County. 2. That I am __________ years of age and my monthly household income is __________________. Proof of income, such last two pay stubs / unemployment check / SSI or disability, is attached. 3. That I live at ___________________________________________________________________ and pay ________________ per month as rent. 4. My household consists of ______ people. I have _______ dependents. 5. That I pay the following bills each month. Name of Bill _____________________________________ _____________________________________ _____________________________________ _____________________________________ Amount of Bill _______________________ _______________________ _______________________ _______________________ 6. That I hereby request that I be able to proceed in this action without having to pay filing fees and associated costs. This __________ day of _______________________________, _______________. _________________________________________ (Sign your name in front of the Notary.) Email Address: ________________________________ IF YOU DO NOT HAVE AN EMAIL ADDRESS, FILL OUT THE ATTACHED CERTIFICATE. Telephone No.: ________________________________ Sworn to and subscribed to me, this ____ day of __________________, ________. _____________________________________ NOTARY PUBLIC My Commission Expires (Notary Seal) Rev. 2015 American LegalNet, Inc. www.FormsWorkFlow.com