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 American LegalNet, Inc. www.FormsWorkFlow.com 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: American LegalNet, Inc. www.FormsWorkFlow.com 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 [ ] American LegalNet, Inc. www.FormsWorkFlow.com 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 $ American LegalNet, Inc. www.FormsWorkFlow.com 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 _____________________ American LegalNet, Inc. www.FormsWorkFlow.com