AOC-275.14 Rev. 1-16 Page 1 of 3 Doc. Code: AIDV COM M O CO NW E A LT H O F K E lex et justitia Case No. Court County Division ____________________ ____________________ U Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS 403.761; 456.100 RT OF JUS TI RESPONDENT'S FINANCIAL STATEMENT, AFFIDAVIT OF INDIGENCY, REQUEST FOR REDUCED GPMS COSTS, AND ORDER C E NT U C KY PETITIONER First Middle Last VS. RESPONDENT First Middle Last Respondent's Address: ____________________________________________________________________________ Age: ________ ) Telephone: ( ___________________________ ) Cell: ( ___________________________ FINANCIAL STATEMENT: 1. Income: Employed? q Yes If Yes: q Full-time q monthly Married? q Yes q No Income from Employment: q biweekly q hourly $_______________ q No q hourly $ ________________ If No, date last employed: _____________________________ If Yes, Spouse Employed? q Yes q monthly If Yes, Spouse's Income from Employment: q Welfare: $ ____________ q biweekly q No q Part-time q Temporary/Seasonal Length of Employment: ___________ Total Income from ALL other source(s) and amount received per month: q Food Stamps:$ ____________ q Social Security/Disability:$ ____________ q Retirement:$ ______________ q Worker's Comp: $ ___________ q Unemployment:$_____________ q Child Support/Maintenance: $ _____________ q Child Care Assistance: $ ___________________ q Stocks, Trusts, Bonds:$______________ q Other : _______________________________________ $ ________________________ Total Income from ALL other source(s): $ ________________________ TOTAL MONTHLY INCOME: 2. Property: Own Real Estate? q Yes q No $ _________________ q No $ _________________ Amount owed : $ _______________ Amount owed : $ _______________ If Yes, Value of Real Estate: Own Mobile Home? q Yes If Yes, Value of Mobile Home: Own Personal Property: Motor Vehicles in Operable Condition (including motor cycles, riding lawn mowers, ATVs, etc.): Make/Model Year: _______________ Make/Model Year: _______________ Make/Model Year: _______________ Bank Accounts: q Yes Value: $ _________________ Value: $ _________________ Value: $ _________________ q No Amount Owed:$ _________________ Amount Owed:$ _________________ Amount Owed:$ _________________ If Yes, total balance of all accounts: $________________________ Other Asset(s) (i.e., boat, jewelry, cash) Asset type: _________________ Asset type: _________________ Value: $ _________________ Value: $ _________________ Amount owed: $ _________________ Amount owed: $ _________________ American LegalNet, Inc. www.FormsWorkFlow.com AOC-275.14 Doc. Code: AIDV Rev. 1-16 Page 2 of 3 3. Dependents: q Yes q No Age(s) of Dependent(s)_______________ If Yes, Number of Dependent(s) (including children, elderly, or disabled): _____________ Relationship of dependent(s):____________ 4. Monthly Expenditures: Mortgage payment/ Rent: q Yes Child support obligation: q Yes q No q No If Yes, amount of payment: $ _________________________________ If Yes, amount of payment: $ _________________________________ Other out-of-pocket monthly bills (FOR HOUSEHOLD): q utilities: $ ___________ q water: $ ___________ q telephone service (land or cell): $ ___________ q car payment: $ _____________ q medical debts: $ ___________ q internet service: $ ___________ q cable/satellite: $ ___________ q tuition: $ ___________ q credit card payments: $ ___________ q car/health/home owners/ renters insurance payments: $ ___________ q unreimbursed childcare: $ ___________ q student loan payments: $ ___________ q Other Financial Obligations: $ _____________________________ $ _______________________________ $ _______________________________ Total of other out-of-pocket monthly bills: TOTAL MONTHLY EXPENDITURES: Request for Reduced GPMS Costs: I state to the court that I am without sufficient financial means or assets to pay the full amount of the costs associated with operating the global positioning monitoring system ("GPMS"). PERJURY WARNING: I understand that knowingly making any false statement in this Financial Statement, Affidavit of Indigency, and Request for Reduced GPMS Costs may subject me to the penalties for perjury as contained in KRS Chapter 523, exposing me to a maximum sentence of five (5) years imprisonment. I declare under the penalty of perjury that I have read or have had read to me the above Financial Statement and Affidavit of Indigency and that the information contained within is true, complete, and accurate to the best of my knowledge. I also further swear to timely inform the Court of any significant changes in any of the information in the above Affidavit of Indigency. ______________________________, 2_____ Date ____________________________________________ Affiant's Signature ______________________________, 2_____ Date ____________________________________________ Signature/Title of Officer Administering Oath American LegalNet, Inc. www.FormsWorkFlow.com AOC-275.14 Rev. 1-16 Page 3 of 3 COM M Doc. Code: OIGPSD OIGPSG O NW E A LT H O F K E lex et justitia Case No. Court County Division ____________________ ____________________ NT U C KY Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS 403.761; 456.100 RT OF JUS TI RESPONDENT'S FINANCIAL STATEMENT, AFFIDAVIT OF INDIGENCY, REQUEST FOR REDUCED GPMS COSTS, AND ORDER ORDER Based upon the above attested statements, IT IS HEREBY ORDERED: 1. The Affiant, _________________________________________________________________________, q is NOT indigent based upon the foregoing Financial Statement and Affidavit, and the Request for Reduced Global Positioning Monitoring System Costs is DENIED. (Doc Code: OIGPSD) q is indigent based upon the foregoing Financial Statement and Affidavit, and the Request for Reduced Global Positioning Monitoring System Costs is GRANTED. 2. (Doc Code: OIGPSG) A partial fee for Reduced Global Positioning Monitoring System Costs: q is NOT assessed. q is assessed in the amount of $ _______________ to be paid in the manner set forth in the GPMS Order and Notification issued by this Court on ___________________________, 2_____. q may be reserved for a later date. ________________________________, 2______ Date C Copies to: Court File Respondent GPMS Provider: ___________________________________________________________ CO U E ___________________________________________ Judge American LegalNet, Inc. www.FormsWorkFlow.com