Commonwealth of Massachusetts AFFIDAVIT OF INDIGENCY AND REQUEST FOR WAIVER, SUBSTITUTION OR STATE PAYMENT OF FEES & COSTS (Note: If you are currently confined in a prison or jail and are not seeking immediate release under G.L. c. 248 §1, but you are suing correctional staff and wish to request court payment of “normal” fees (for initial filing and service), do not use this form. Obtain separate forms from the clerk.) ______________________________ Court __________________________________________________________ Case Name and Number (if known) Name of applicant Address (Street and number) SECTION 1: •• •• •• (City or town) (State and Zip) Under the provisions of General Laws, Chapter 261, Sections 27A-27G, I swear (or affirm) as follows: I AM INDIGENT in that (check only one): (A) I receive public assistance under Transitional Aid to Families with Dependent Children (TAFDC). Emergency Aid to Elderly, Disabled or Children (EAEDC), Supplemental Security Income (SSI), Medicaid (MassHealth) or Massachusetts Veterans Benefits Programs; (circle form of public assistance received); or (B) My income, less taxes deducted from my pay, is $_____________ per week/month/year (circle period that applies), for a household of ______ persons, consisting of myself and _____ dependents; which income is at or below the court system's poverty level; (Note: The court system's poverty levels for households of various sizes must be posted in this courthouse. If you cannot find it, ask the clerk. The court system’s poverty level is updated each year.) [List any other available household income for the circled period on this line: _____________) or (C) I am unable to pay the fees and costs of this proceeding, or I am unable to do so without depriving myself or my dependents of the necessities of life, including food, shelter and clothing. IF YOU CHECKED (C), YOU MUST ALSO COMPLETE THE SUPPLEMENT TO THE AFFIDAVIT OF INDIGENCY. SECTION 2: (Note: In completing this form, please be as specific as possible as to fees and costs known at the time of filing this request. A supplementary request may be filed at a later time, if necessary.) I request that the following NORMAL FEES AND COSTS be waived (not charged) by the court, or paid by the state, or that the court order that a document, service or object be substituted at no cost (or a lower cost, paid for by the state): (Check all that apply and, in any "$____" blank, indicate your best guess as to the cost, if known.) •• •• •• Filing fee and any surcharge. $ _____________ Filing fee and any surcharge for appeal. $ _______________ Fees or costs for serving court summons, witness subpoenas or other court papers. $______________ American LegalNet, Inc. www.FormsWorkFlow.com •• Other fees or costs of $__________for (specify): •• Substitution (specify): SECTION 3: I request that the following EXTRA FEES AND COSTS either be waived (not charged), substituted or paid for by the state: •• Cost, $_______, of expert services for testing, examination, testimony or other assistance (specify): •• Cost, $_______, of taking and/or transcribing a deposition of (specify name of person): •• Cassette copies of tape recording of trial or other proceeding, needed to prepare appeal for applicant not represented by Committee for Public Counsel Services (CPCS-public defender). •• Appeal bond •• Cost, $_______, of preparing written transcript of trial or other proceeding •• Other fees and costs, $_______, for (specify) •• Substitution (specify) Date signed Signed under the penalties of perjury x By order of the Supreme Judicial Court, all information in this affidavit is CONFIDENTIAL. Except by special order of a court, it shall not be disclosed to anyone other than authorized court personnel, the applicant, applicant's counsel or anyone authorized in writing by the applicant. This form prescribed by the Chief Justice of the SJC pursuant to G.L. c. 261, § 27B. Promulgated March , 2003 American LegalNet, Inc. www.FormsWorkFlow.com