Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS 403.761(9)(b); KRS 189A.420 COMMONWEALTH OF KENTUCKY VS. U RT OF JUS TI C E AOC-495.8 Rev. 7-15 Page 1 of 2 Doc. Code: AOII COM M O CO NW E A LT H O F K E lex et justitia Case No. ____________________ Court County Division ____________________ ____________________ ____________________ PLAINTIFF FINANCIAL STATEMENT, AFFIDAVIT OF INDIGENCY, AND REQUEST FOR REDUCED IGNITION INTERLOCK DEVICE COSTS NT U C KY _______________________________________________ Address:________________________________________ _______________________________________________ () Telephone: _____________________________ FINANCIAL STATEMENT: 1. Income: Employed? If Yes: [ ] Yes [ ] Full-time [ ] monthly [ ] No [ ] Part-time [ ] biweekly DEFENDANT [ ] Temporary/Seasonal Length of Employment: ___________ [ ] hourly $_______________ Income from Employment: If No, date last employed: _____________________________ Married? [ ] Yes [ ] No If Yes, Spouse Employed? [ ] monthly [ ] biweekly [ ] Yes [ ] No If Yes, Spouse's Income from Employment: [ ] Welfare: $__________ [ ] hourly $________________ Total Income from ALL other source(s) and amount received per month: [ ] Food Stamps:$ ___________ [ ] Social Security/Disability:$____________ [ ] Worker's Comp: $________ [ ] Unemployment:$____________ [ ] Retirement:$____________ [ ] Stocks, Trusts, Bonds:$______________ [ ] Other : __________________ $________________________ [ ] Child Support/Maintenance: $__________ [ ] Child Care Assistance: $___________________ Total Income from ALL other source(s): $ _______________________ TOTAL MONTHLY INCOME: 2. Property: Own Real Estate? Own Mobile Home? Own Personal Property: Motor Vehicles in Operable Condition (including motor cycles, riding lawn mowers, ATVs, etc.): Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________ Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________ Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________ Bank Accounts: [ ] Yes [ ] No If Yes, total balance of all accounts: $________________________ Other Asset(s) (i.e., boat, jewelry, cash) Asset type: _________________ Value: $ _________________ Amount owed: $_______________ Asset type: _________________ Value: $ _________________ Amount owed: $_______________ American LegalNet, Inc. www.FormsWorkFlow.com [ ] Yes [ ] Yes [ ] No $_________________ [ ] No $_________________ Amount owed : $_______________ Amount owed : $_______________ If Yes, Value of Real Estate: If Yes, Value of Mobile Home: AOC-495.8 Rev. 7-15 Page 2 of 2 Doc. Code: AOII 3. Dependents: [ ] Yes [ ] 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: [ ] Yes Child support obligation: [ ] Yes [ ] No [ ] No If Yes, amount of payment: $_________________________________ If Yes, amount of payment: $_________________________________ Other out-of-pocket monthly bills (FOR HOUSEHOLD): [ ] utilities: $_____________ [ ] water: $_____________ [ ] telephone service (land or cell): $_____________ [ ] car payment: $_____________ [ ] internet service: $_____________ [ ] cable/satellite: $_____________ [ ] credit card payments: $_____________ [ ] car/health/home owners/renters insurance payments: $_____________ [ ] unreimbursed childcare: $_____________ [ ] student loan payments: $_____________ [ ] tuition: $_____________ [ ] medical debts: $_____________ [ ] Other Financial Obligations: $_____________ $_______________________________ $_______________________________ Total of other out-of-pocket monthly bills: TOTAL MONTHLY EXPENDITURES: Request for Reduced Ignition Interlock Device 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 leasing or purchasing, installing, servicing and monitoring interlock device. PERJURY WARNING: I understand that knowingly making any false statement in this Financial Statement, Affidavit of Indigency, and Request for Reduced Ignition Interlock Device 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