07/01/13 1 IN THE JUDICIAL DISTRICT DISTRICT COURT OF COUNTY, KANSAS , ) ) Plaintiff, ) ) vs. ) Case No. ) , ) ) Defendant. ) POVERTY AFFIDAVIT - INMATE Note: Do not use this form if you are filing a motion under K.S.A. 60-1507. Use the forms relating to Supreme Court Rule 183. I, , inmate number , am currently an inmate in the custody of the secretary of corrections and am unable to pay the full amount of the 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 other sources (list amount per week): Employment income (after withholdings) is: $ 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, prison 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 the full amount of the 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 full amount of the docket fee. Executed on , 20 . Signature of Plaintiff NOTE: you must attach to this affidavit a certified inmate account statement setting forth the lesser of the average account balance or total deposits in your inmate trust fund for the 6-month period preceding the filing of this affidavit or the current period of incarceration, whichever is shorter. American LegalNet, Inc. www.FormsWorkFlow.com