Circuit Court Information Name: Case No.: STATE OF MICHIGAN COURT OF APPEALS Affidavit Concerning Financial Status Court of Appeals Information Case No.: Case Name: Name: Address & Telephone No.: The following is information concerning my present financial status. 1. PUBLIC ASSISTANCE I am currently receiving public assistance because of indigency: Yes No If YES, state the type of assistance and identify the government agency that provides it. 2. RESIDENCE $ per month Rent Mortgage Room/Board Live with Relatives 3. MARITAL STATUS Single Married Divorced Separated Dependents: Number b. Length of Employment 4. INCOME a. Employer name, address & telephone no. c. Average pay weekly monthly every two weeks Gross: $ Net: $ d. Other income (State monthly amount and source, such as DHS, VA, rent, pension, spouse, unemployment, etc. If no income, state NONE.) 5. ASSETS (State value of car, home, bank deposits, bonds, stocks, etc. If no assets, state NONE.) 6. OBLIGATIONS (Itemize monthly rent, installment payments, mortgage payments, child support, etc.) Signature Date Subscribed and sworn to before me on,County, Michigan Date My commission expires: Signature: Date Notary public Notary public, State of Michigan, County of COURT OF APPEALS AFFIDAVIT CONCERNING FINANCIAL STATUS Aug 2009 American LegalNet, Inc. www.FormsWorkFlow.com