Commonwealth of Massachusetts SUPPLEMENT TO AFFIDAVIT OF INDIGENCY AND REQUEST FOR WAIVER, SUBSTITUTION OR STATE PAYMENT OF FEES & COSTS (Note: If you checked (C) on the AFFIDAVIT OF INDIGENCY, you must complete this form.) ______________________________ Court __________________________________________________________ Case Name and Number (if known) Name of applicant Address (Street and number) (City or town) (State and Zip) Under the provisions of General Laws, Chapter 261, Sections 27A-G, I swear or affirm as follows: 1. PERSONAL INFORMATION (a) (b) Highest Grade Attained in School: (c) Special Training: (d) List any physical or mental disabilities which you wish to reveal and which affect your earning capacity or living expenses: (e) 2. Date of Birth: Number of Dependents: INCOME AFTER TAXES (monthly): (a) If from employment, list your occupation and your employer’s name and address: (b) Source of income, if not from employment: (c) My gross annual income for the past twelve months was: $ American LegalNet, Inc. www.FormsWorkflow.com (d) Gross Income (monthly): (e) $ Taxes Deducted (monthly): Federal Tax $_______________ State Tax $_______________ Social Security $_______________ Medicare $_______________ Other Taxes (specify) $_______________ Total Taxes Deducted (f) Total Income After Taxes (subtract 2(e) from 2(d)): $ (g) 3. $ If any other member of your household is employed, list occupation and name and address of his/her employer and monthly income after taxes:___________________________________________________ NET INCOME (monthly): (a) Income After Taxes (from Line 2(f)): (b) $ Expenses (monthly): Rent or Mortgage $____________ Uninsured Medical Expenses $____________ Food $____________ Child Care $____________ Electricity $____________ Education Expenses for Children $____________ Gas $____________ Child Support $____________ Oil $____________ Clothing $____________ Water $____________ Laundry/Cleaning $____________ Telephone $____________ Car Insurance $____________ Health Insurance $____________ Transportation Expenses $____________ Other (specify): $__________________________________ _____________________________________________________ Total Expenses (c) $ Income After Taxes Minus Expenses (monthly) (subtract 3(b) from 3(a)): $ American LegalNet, Inc. www.FormsWorkflow.com 4. ASSETS (a) Own home? ________________________ Market Value $ _______________________ Year & Make _______________________ Balance owed $_______________________ (b) Own Car? ________________________ Market Value $_______________________ Balance Owed $_______________________ (c) (d) 5. Bank Accounts (specify type and balance) Other Property Including Real Estate (specify type and value) DEBTS (a) 6. Specify: MISCELLANEOUS (a) Other facts which may be relevant to your ability to pay fees and costs? Signed under the penalties of perjury: Signature: Type/Printed Name: Address: Date: 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