07/01/13 1 IN THE JUDICIAL DISTRICT DISTRICT COURT OF COUNTY, KANSAS , ) ) Plaintiff, ) ) vs. ) Case No. ) , ) ) Defendant. ) POVERTY AFFIDAVIT Note: Do not use this form if you are currently an inmate in the custody of the secretary of corrections. You should use the Poverty Affidavit 226 Inmate form or, if you are filing a motion under K.S.A. 60-1507, you should use the forms relating to Supreme Court Rule 183. I, , am unable to pay a docket fee in this matter by reason of poverty. Pursuant to K.S.A. 60-2001(b)(2), the following information is provided in support. Employment: I am employed; not employed. My employer is: My employer222s address is: Income: I receive income from the following sources (list amount per week): Employment income (after withholdings): $ Rental income: $ Interest and / or dividends: $ Spousal support and / or child support: $ Retirement, pension, social security: $ Disability, workers compensation: $ Unemployment benefits: $ American LegalNet, Inc. www.FormsWorkFlow.com 2 Other Income (Describe) $ TOTAL weekly income from all sources: $ Assets on Hand: I presently have the following assets (list value): Cash (including bank accounts and electronic accounts): $ Automobile, truck or other vehicle: $ Real property (home, building or land): $ Other assets (jewelry, watches, etc.) $ Other Assets: Are you a beneficiary of any current estate, trust, annuity, or life insurance policy? If so, please provide the details. . Other Reasons: Explain any other facts or reasons why you cannot afford to pay a docket fee in your case. . I, , declare under penalty of perjury that the information set forth in this affidavit is true and correct and that, by reason of my poverty, I am unable to pay the docket fee. Executed on , 20 . Signature of Plaintiff American LegalNet, Inc. www.FormsWorkFlow.com