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Affidavit Of Indigency Form. This is a New Mexico form and can be use in 1st Judicial District Local District Court.
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Tags: Affidavit Of Indigency, New Mexico Local District Court, 1st Judicial District
STATE OF NEW MEXICO
COUNTY OF ____________________
_______________________________
Petitioner,
v.
No.__________________________
_______________________________
Respondent.
AFFIDAVIT OF INDIGENCY
STATE OF NEW MEXICO
)
) ss.
COUNTY OF __________________)
I, ______________________________, make under oath the following statements regarding my
financial, marital and employment status, and since I am unable to pay for an attorney to
represent me in the above-captioned case, make application to proceed in accordance with
Administrative Order No. 2004-4.
BACKGROUND AND RESIDENCE
1.
Full name: ________________________________________
2. Age:______
3.
Present address: ____________________________________________________
____________________________________________________
4.
How many years at this address? _______ 5. Telephone No. ________________
6.
Marital Status: Married [ ] Single [ ] Divorced [ ] Separated [ ]
Children
Adult
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7.
Number of dependents (including yourself):
8.
Ages of minor children living with you: _________________________________
9.
List name and relationship of adult dependents whom you support:
Name:
_________
_________
Relationship:
EMPLOYMENT AND INCOME:
1
Employed [ ] Not Employed [ ] Self-employed [ ]
2.
Name and address of employer:
_________________________________________________________________
_________________________________________________________________
3.
Position: _________________________________________________________
4.
Gross salary per month: $_______________
5.
If self-employed, nature of business: ___________________________________
_________________________________________________________________
_________________________________________________________________
OTHER INCOME:
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In addition to wages and salary, I receive the following income:
A.
Social Security / Disability
$______________________
B.
Welfare
$______________________
C.
Unemployment
$______________________
D.
Food Stamps
$______________________
E.
AFDC
$______________________
F.
VA
$______________________
G.
Child Support
$______________________
H.
Alimony
$______________________
I.
Investments
$______________________
Total:
$______________________
ASSETS
1.
Do you own any real estate?
Yes [ ] No [ ]
A.
B.
Location:___________________________________________________
C.
Estimated present value $_______________
D.
Estimated outstanding mortgages or contracts on property:$___________
E.
2.
Description:_________________________________________________
Payments per month:$__________________
Do you own any automobiles?
Yes [ ] No [ ]
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A.
Year ________
_______________
B.
Make/Model_______________
________
Present Value $_____________ Total Amount Owed $_____________
$_____________
C.
$_____________
Monthly payments $_________
$_________
3.
Do you have any stocks or bonds?
Yes [ ] No [ ]
A.
B.
4.
Description_________________________________________________
Present Value $_______________
Do you have cash in the bank?
A.
5.
Yes [ ] No [ ]
If so, indicate amount $_________
Do you have any other assets not listed above excluding household furnishings
and clothing?
A.
Yes [ ] No [ ]
If so, describe and give value __________________________________
____________________________________Value: $_______________
DEBTS AND OTHER OBLIGATIONS:
1.
The following are my current obligations:
A.
House payment / rent per month
$
B.
Utilities per month
$
C.
Telephone per month
$
D.
Groceries
$
E.
Gasoline
$
F.
Insurance
$
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G.
Medical Bills
$
H.
Child Care
$
I.
Other
$
J.
Other
$
Total: $
_________________________________
SIGNATURE OF APPLICANT
SUBSCRIBED AND SWORN TO before me by _______________________________ this
_______________ day of _________________________, ________________.
_________________________________________
My Commission Expires:
NOTARY PUBLIC
_____________________
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