Affidavit Of Indigency
Affidavit Of Indigency Form. This is a Massachusetts form and can be use in General Statewide.
Tags: Affidavit Of Indigency, Massachusetts Statewide, General
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Commonwealth of Massachusetts Index No. : Calendar No. AFFIDAVIT OF INDIGENCY SUBPOENA : JUDICIAL Plaintiff(s) AND -against- 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.) Defendant(s) : ...................................................... ______________________________ __________________________________________________________ Court Case Name and Number (if known) THE PEOPLE OF THE STATE OF NEW YORK Name of applicant TO Address (Street and number) (City or town) (State and Zip) SECTION 1: Under the provisions of General Laws, Chapter 261, Sections 27A-27G, I swear (or affirm) as follows: GREETINGS: I AM INDIGENT in that (check only one): WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable public assistance under Transitional Aid to Families with Dependent Children (TAFDC). at the Court (A) I receive located at Children (EAEDC), Supplemental Security Income (SSI), Medicaid County of Emergency Aid to Elderly, Disabled or in room , on the day Veterans Benefits Programs; (circle formin the , 20 , at o'clock of public assistance received); or noon, and at any recessed (MassHealth) or Massachusetts of or adjourned date, to testify and give evidence as a witness in this action on the part of the 9 9 9 (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 Your failure to comply poverty subpoena is The court system's poverty levels and will make you liable or below the court system's with thislevel; (Note: punishable as a contempt of courtfor households of various to the party on whoseposted in this courthouse. If you cannotmaximum penalty of $50 and allsystem’s poverty level a sizes must be behalf this subpoena was issued for a find it, ask the clerk. The court damages sustained as result is updated eachto comply. any other available household income for the circled period on this line: of your failure year.) [List _____________) or Witness, Honorable , one of the Justices of the Court in I am unable to pay the feesday of County, , 20 (C) and costs of this proceeding, or I am unable to do so without depriving myself or my dependents of the necessities of life, including food, shelter and clothing. IF YOU CHECKED (C), YOU MUST ALSO COMPLETE THE SUPPLEMENT TO THE AFFIDAVITbelow) (Attorney must sign above and type name OF INDIGENCY. SECTION 2: (Note: In completing this form, please be as specific as possible as to fees and costs known at the time of Attorney(s) time, filing this request. A supplementary request may be filed at a laterfor if necessary.) I request that the following NORMAL FEES AND COSTS be waived (not charged) by the court, or paid by the state, or that the court order that a document, service or object be substituted at no cost (or a lower cost, paid for by the state): (Check all that apply and, in any "$____" blank, indicate your best Office and P.O. Address guess as to the cost, if known.) 9 9 9 Filing fee and any surcharge. $ _____________ Telephone No.: Facsimile No.: Filing fee and any surcharge for appeal. $ _______________ E-Mail Address: Fees or costs for serving court summons, witness subpoenas orMobilecourt No.: $______________ other Tel. papers. American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 9 : Calendar No. : JUDICIAL SUBPOENA Other fees or costs of $__________for (specify): Plaintiff(s) -against- 9 Index No. : Substitution (specify): : : FEES AND SECTION 3: I request that the following EXTRADefendant(s) COSTS either be waived (not charged), substituted or : . . . . . . . . paid. for. by .the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . state: 9 Cost, $_______, of expert services for testing, examination, testimony or other assistance (specify): THE PEOPLE OF THE STATE OF NEW YORK TO 9 9 9 9 9 9 Cost, $_______, of taking and/or transcribing a deposition of (specify name of person): GREETINGS: Cassette copies of tape recording of trial or other proceeding, needed to prepare appeal for applicant not WE COMMAND for Public all business and excuses being laid aside, you and each of you attend before represented by Committee YOU, that Counsel Services (CPCS-public defender). , the Honorable at the Court located at County of inAppeal bond room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Cost, $_______, of preparing written transcript of trial or other proceeding Your failure $_______, for this subpoena is punishable as a contempt of court and will make you liable to Other fees and costs,to comply with (specify) the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Substitution (specify) Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Date signed Signed under the penalties of perjury Attorney(s) for 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, Office applicant's counsel or anyone authorized in writing by the applicant. and P.O. Address This form prescribed by the Chief Justice of the SJC pursuant to G.L. c. 261, § 27B. Promulgated March , 2003 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com