THE COURT OF APPEALS OF THE STATE OF NEW MEXICO ____________________________ Name of Plaintiff/Petitioner, Court of Appeals Case No. _____________ vs. District Court Case No. _______________ ____________________________ Name of Defendant/Respondent. _________________________________/ APPLICATION FOR FREE PROCESS AND AFFIDAVIT OF INDIGENCY I request that the Court enter an order permitting me to file this case without prepayment of fees and costs, and give upon my oath or affirmation the following statement: My marital status is (check one): 9 Single 9 Married 9 Divorced 9 Separated 9 Widowed Are you currently living in an institution, for example, a correctional facility, where you do not have to pay for your usual living expenses? (check one) 9 Yes 9 No INFORMATION ABOUT MY FINANCES (Check all that apply to you and fill in Domestic Relations Appeals 7 American LegalNet, Inc. www.FormsWorkFlow.com the blanks): A. PUBLIC ASSISTANCE 9 I do not receive public assistance (If you check this blank, go directly to Section B. EMPLOYMENT/UNEMPLOYMENT). 9 I currently receive the following public assistance in _______________ County (please check all applicable public assistance programs): 9 Temporary Assistance for Needy Families (TANF) 9 Food Stamps 9 General Assistance (GA) 9 Medicaid 9 Supplemental Security Income (SSI) 9 Social Security Disability Income (SSDI) 9 Public Housing 9 Disability Security Income (DSI) 9 Department of Health Case Management Services (DHMS) 9 Other (please describe): ___________________________________. B. EMPLOYMENT/UNEMPLOYMENT (c) I am currently unemployed and have been employed for ____ months in the past year. I am unemployed because _______________________________ _____________________________________________________________ (a) (b) (c) I receive unemployment benefits in the amount of $______ per month. I have no income because I am unemployed. I am employed. My employer's name, address and phone number is: Domestic Relations Appeals 8 American LegalNet, Inc. www.FormsWorkFlow.com _____________________________________________________ _____________________________________________________ _____________________________________________________ I am paid 9 weekly 9 every other week 9 twice a month 9 once a month. When I am paid my net take-home pay minus deductions required by law, like state and federal tax withholding and FICA, is $_________________. 9 I am married and my spouse is unemployed and has been unemployed for ____ months in the past year because ______________________________. 9 My spouse receives unemployment benefits in the amount of $_____ per month. 9 I am married, and my spouse is employed. My spouse's employer's name, address and phone number is: _____________________________________________________ _____________________________________________________ _____________________________________________________ My spouse is paid 9 weekly 9 every other week 9 twice a month 9 once a month. When my spouse is paid his or her net take-home pay minus deductions required by law, like state and federal tax withholding and FICA, is $_________________. C. OTHER SOURCES OF INCOME Domestic Relations Appeals 9 American LegalNet, Inc. www.FormsWorkFlow.com 9 I have income from another source not mentioned above. 9 Child Support $_________ 9 Alimony $_________ 9 Investments $_________ 9 Community property from my spouse $_________ 9 Other ________________________ $_________ 9 9 I do not have any other sources of income. I am married, and my spouse has income from another source not mentioned above. 9 Child Support $_________ 9 Alimony $_________ 9 Investments $_________ $_________ $_________ 9 Other __________________________ 9 Other __________________________ 9 D. I am married, and my spouse does not have any other sources of income. OTHER ASSETS (Please list other assets owned by you or your spouse that can be turned into cash. Do not include money you have in retirement accounts. 9 Cash on hand 9 Bank Accounts 9 Income tax refund 9 Other assets (describe below): __________________________________ $___________ $ __________ $ __________ $ __________ Domestic Relations Appeals 10 American LegalNet, Inc. www.FormsWorkFlow.com IF YOU DO NOT HAVE ACCESS TO YOUR OWN OR YOUR SPOUSE'S INCOME OR ASSETS, EXPLAIN WHY. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ ___________________________________________________________________ E. MONTHLY EXPENSES House Payment/Rent Telephone $________ $________ Utilities Gasoline $_______ $_______ Groceries (after food stamps) $________ Insurance Student & Consumer Loans Court-ordered family support obligations Other court-ordered payments Medical expenses Other _____________________________ F. HOUSEHOLD I live at: $ ________ Car Payment(s) $_______ Child Care $_______ $_______ $_______ $_______ $_______ $_______ ____________________________________________________ and the head of the household is: ___________________________________. Other than myself, the other members of the household are: Name Domestic Relations Appeals Age 11 Employment I Support American LegalNet, Inc. www.FormsWorkFlow.com ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ______ _____________ 9 ______ ______ ______ ______ ______ _____________ _____________ _____________ _____________ _____________ 9 9 9 9 9 This statement is made under oath. I hereby state that the above information regarding my financial condition is correct to the best of my knowledge. I hereby authorize the Court to obtain information from financial institutions, employers, relatives, the federal internal revenue service and other state agencies. If at any time the Court discovers that information in this application for free process was false, misleading, inaccurate, or incomplete at the time the application was submitted, the Court may require me to pay for any costs or fees that were waived under an order of free process that was granted based on the information in this application. _________________________________ (Signature) _________________________________ (Print Name) 9 Petitioner(Pro Se) 9 Respondent (Pro Se) _________________________________ (Street Address) _________________________________ (City, State,