IN THE SUPERIOR COURT OF FULTON COUNTY STATE OF GEORGIA FAMILY DIVISION In re the Family of: Petitioner: _____________________________ Civil Action File No: ____________________ and Respondent: ___________________________ POVERTY AFFIDAVIT Comes now _____________________________ , the Petitioner in the above styled __________________ ________________________________ (name of petition), being first duly sworn, deposes and says: 1. That I, by reason of my poverty, am unable to pay the cost required by O.C.G.A. §15-6-77 to file a civil case, in the Courts of Fulton County. 2. That I am _______________ years of age, and my monthly household income is __________________ . A copy of my last two pay stubs/unemployment checks is attached. 3. That I live at _______________________________________________ , and pay ________________ ____________per month as rent. 4. My household consists of __________________ number of people. 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 the ________ day of ____________________ , _____ . (Sign your name here in front of the Notary or Judge ) Address: _____________________________________ Telephone number: ( Sworn to and subscribed before me, this ____ day of _______________________ , _______ . ) NOTARY PUBLIC/ JUDGE My Commission Expires: (Notary Seal) Page 1 of 1 Poverty Affidavit Form ©2006 Fulton County Superior Court Family Division American LegalNet, Inc. www.FormsWorkflow.com