IN THE STATE COURT OF GWINNETT COUNTY STATE OF GEORGIA ) ) ) Plaintiff, ) ) CIVIL ACTION v. ) FILE NO. ) ) ) ) Defendant(s). ) ) AFFIDAVIT OF ELIGIBILITY TO PROCEED IN FORMA PAUPERIS I,, do hereby swear or affirm that I am the [ ] Plaintiff [ ] Defendant in the above styled case and that because of my indigent status, I am unable to pay the costs of this proceeding. I declare under penalty of perjury that the responses I have made to all questions set forth in this Affidavit, specifically relating to my ability to pay the costs of this proceeding, are true and correct. This day of , 20. Signature Print name: Sworn to and subscribed before me Sworn to and subscribed before me thisday of,20 thisday of,20 Notary Public Deputy Clerk of State Court American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT, Page 2 A. IDENTIFYING INFORMATION 1. Name: Last First Middle 2. Current Address: Street Address & Apt. No., if applicable City State Zip Code 3. Best Telephone Number to Reach You: 4. Email Address: B. DEPENDENTS/DEPENDENCY 1. Marital Status: [ ] Married [ ] Single [ ] Divorced/Separated. 2. Is there any other person (spouse) or people (parents) who currently support you financially? [ ] Yes [ ] No. If yes, explain: 2. How many people, not including yourself, do you currently support? List Below: Name Age Relationship Support Totally? [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No C. PUBLIC ASSISTANCE Do you currently receive any of the following? Aid to Families of Dependent Children (AFDC) [ ] Yes [ ] No Amount Received per Month: $ Social Security Income (SSI) [ ] Yes [ ] No Amount Received per Month: $ American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT, Page 3 Social Security Disability Income (SSDI) [ ] Yes [ ] No Amount Received per Month: $ Temporary Assistance to Needy Families (TANF) [ ] Yes [ ] No Amount Received per Month: $ Supplemental Nutrition Assistance Program (SNAP) [ ] Yes [ ] No Amount Received per Month: $ Unemployment Benefits [ ] Yes [ ] No Amount Received per Month: $ Medicaid [ ] Yes [ ] No Amount Received per Month: $ Public Housing Assistance [ ] Yes [ ] No Amount Received per Month: $ Do you receive any other kind of public assistance? [ ] Yes [ ] No Amount Received per Month: $ TOTAL AMOUNT OF PUBLIC ASSISTANCE RECEIVED PER MONTH, IF ANY: $ D. MONTHLY INCOME 1. Are you currently employed? [ ] Yes [ ] No If yes, please list name(s) and phone number(s) of your employer(s), as well as monthly income/wages. Employer Name Phone Amout Paid per Month TOTAL AMOUNT OF INCOME RECEIVED PER MONTH, IF ANY: $ 2. Do you receive any income from any other source? [ ] Yes [ ] No If yes, please list all other income sources on the following page. American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT, Page 4 Workers Compensation Benefits [ ] Yes [ ] No Amount Received per Month: $ Insurance Benefits/Proceeds [ ] Yes [ ] No Amount Received per Month: $ Pension/Retirement Income [ ] Yes [ ] No Amount Received per Month: $ Child Support Payments [ ] Yes [ ] No Amount Received per Month: $ Alimony Payments [ ] Yes [ ] No Amount Received per Month: $ TOTAL AMOUNT OF INCOME FROM OTHER SOURCES RECEIVED PER MONTH, IF ANY: $ E. ASSETS 1. Do you have a checking account? [ ] Yes [ ] No If so, at what financial institution: What is the current balance in your account: $ 2. Do you have a savings account? [ ] Yes [ ] No If so, at what financial institution: What is the current balance in your account: $ 3. Do you own any car(s), truck(s), van(s) or other vehicle(s)? [ ] Yes [ ] No Make: Model: Year: What is the approximate value of the vehicle: $ Make: Model: Year: What is the approximate value of the vehicle: $ 4. Do you own a home or other real estate? [ ] Yes [ ] No Address: Street City State Zip Code What is the approximate value of the property: $ How much do you owe on the property (mortgage balance): $ American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT, Page 5 5. Do you own any valuable items of personal property, such as TV sets, stereos, stocks or bonds, jewelry, furs, or other items? (Do not include clothing, furniture, or household appliances such as stoves or refrigerators.) [ ] Yes [ ] No If yes, please describe below: Description Value $ $ $ Total: $ F. LIABILITIES 1. List all debts owed over $100 and all payments which you must make on a regular basis. Include house payments, rent, child support or alimony payments, charge account payments, loan payments and any other payment which you must make on a regular basis. Do not include ordinary expenses such as food, clothing, utility bills and similar items. Source of Debt Total Amount Owed Monthly Payment Total: $ 2. Do you have any unusual or extraordinary expenses or circumstances such as large medical bills which are not listed above? [ ] Yes [ ] No If yes, please describe below: Source of Debt Total Amount Owed Monthly Payment American LegalNet, Inc. www.FormsWorkFlow.com Total: $ AFFIDAVIT, Page 6 3. Are there any other circumstances which render you unable to pay the costs of this action and are not fully explained above: (e.g. disability, illness, etc.) [ ] Yes [ ] No If yes, use the space below to explain your circumstances. Include any facts which will help the Court determine whether you can afford to pay the required fee(s). American LegalNet, Inc. www.FormsWorkFlow.com