Affidavit Of Financial Status Form. This is a Missouri form and can be use in District Court Federal.
Tags: Affidavit Of Financial Status, Missouri Federal, District Court
UNITED STATES DISTRICT COURT WESTERN DISTRICT OF MISSOURI ) ) ) ) ) ) ) Plaintiff vs. Defendant Case No. AFFIDAVIT OF FINANCIAL STATUS I, , declare that I am the plaintiff in this case, that because of my poverty I am unable to pay the costs of these proceedings, and that I believe I am entitled to relief. I further swear that the responses which I have made to the questions below and the information I have given relating to my ability to pay the costs of commencing and prosecuting this action are true. I. MARITAL STATUS AND PERSONAL DATA A. Single: B. Name of Spouse C. Age of plaintiff, petitioner or complainant: D. Age of spouse: E. Address of plaintiff, petitioner or complainant: Married: Separated: Divorced: Telephone: F. Address of spouse: Telephone: American LegalNet, Inc. www.FormsWorkflow.com G. II. State name or names of dependents who live with you, their age, address, relationship, and how much of their monthly support you provide: EMPLOYMENT A. Name of employer: Address of employer: Employer's telephone: Length of employment: Job title or description: Net Income: Monthly $ Weekly $ Gross Income: Monthly $ Weekly $ Does employer provide health insurance: Yes No If employer provides health insurance, describe coverage: B. Previous employment (Answer only if presently unemployed). Name of employer: Address of employer: Employer's telephone: Length of employment: Job title or description: Net Income: Weekly $ Gross Income: C. Monthly $ Monthly $ Weekly $ Employment of spouse: Name of employer: Page 2 American LegalNet, Inc. www.FormsWorkflow.com Address of employer: Employer's telephone: Length of employment: Job title or description: Net Income: Weekly $ Gross Income: III. Monthly $ Monthly $ Weekly $ FINANCIAL STATUS (Answer questions on behalf of both the plaintiff, petitioner or complainant and spouse). A. Owner of real property? Yes No If yes - Description: Address: In whose name? Estimated value: Total amount owed: Owed to: Annual income from property: B. Owner of automobile: Yes No If yes - Number of automobiles owned: Make Model Year Make Model Year In whose name registered? Present value: Amount owed on the automobile(s): Owed to: Monthly payment(s): Page 3 American LegalNet, Inc. www.FormsWorkflow.com C. Cash on hand: (Include checking and savings accounts) $ List names and addresses of banks and associations: Please do not state account numbers: D. Have you received within the past 12 months any money from any of the following sources: Yes No Rent payments, interest or dividends: Pensions, trust funds, annuities or life insurance payments? Gifts or inheritances? Welfare payments? ADC or other governmental child support? Unemployment benefits? Social Security benefits? Other sources? E. IV. If the answer to any item in D above was "Yes", describe each source of money and state the amount received from each during the past 12 months: OBLIGATIONS A. Monthly rental on house or apartment: B. Monthly mortgage payments on house: Amount of equity in house: Page 4 American LegalNet, Inc. www.FormsWorkflow.com C. Monthly mortgage payments on other properties: $ Amount of equity in other properties: $ D. Household expenses: Monthly grocery expense: Monthly utilities: Gas: Electric: Water: Other: (Specify) E. Other debts and miscellaneous monthly expenses: TO WHOM OWED AND FOR WHAT REASON INCURRED? V. MONTHLY PAYMENTS BALANCE DUE OTHER INFORMATION PERTINENT TO FINANCIAL STATUS (Include information regarding stocks, bonds, savings bonds, either individually or jointly owned). Page 5 American LegalNet, Inc. www.FormsWorkflow.com I understand that a false statement or answer to any question in this affidavit will subject me to penalties of perjury. Signature of Plaintiff VERIFICATION State of County of ) ) ) I, being first duly sworn under oath, state that I know the contents of this affidavit and that the information contained in the affidavit is true to the best of my knowledge and belief. Signature of Plaintiff or Plaintiffs All parties must verify SUBSCRIBED AND SWORN TO before me this day of , 20 Notary Public My Commission Expires Page 6 American LegalNet, Inc. www.FormsWorkflow.com