Rev091213taj STATE OF NEW MEXICO COUNTY OF BERNALILLO SECOND JUDICIAL DISTRICT COURT , Plaintiff v. No. , Defendant APPLICATION FOR FREE PROCESS AND AFFIDAVIT OF INDIGENCY My marital status is: Single Married Divorced SeparatedWidowed I request interpretation services: yes no (If yes, please describe what you need) INFORMATION ABOUT MY FINANCES (check all that apply to you and fill in the blanks): A. PUBLIC ASSISTANCE I do not receive public assistance. (If you check this blank, go directly to Section B EMPLOYMENT/UNEMPLOYMENT). I currently receive the following public assistance in County (please check all applicable public assistance programs): Temporary Assistance for Needy Families (TANF) Food Stamps Medicaid General Assistance (GA) Supplemental Security Income (SSI) Social Security Disability Income (SSDI) Public Housing Disability Security Income (DSI) Department of Health Case Management Services (DHMS) Other (please describe ) B. EMPLOYMENT/UNEMPLOYMENT I am currently unemployed and have been unemployed for months in the past year. I am unemployed because . I receive unemployment benefits in the amount of $ per month. I have no income because I am unemployed. I am employed. I am paid $ per hour and work hours per week. My employer's name, address and phone number is: American LegalNet, Inc. www.FormsWorkFlow.com Rev091213taj I am married, and my spouse is unemployed and has been unemployed for months in the past year because My spouse receives unemployment benefits in the amount of $ per month. I am married, and my spouse is employed. My spouse is paid $ per hour and works hours per week. employer's name, address and phone number is: C. OTHER SOURCES OF INCOME (Check all that apply) I have income from another source not mentioned above. Child Support $ Alimony $ Investments $ Community property from my spouse $ Other $ I do not have any other sources of income. I am married, and my spouse has income from another source not mentioned above. Child Support $ Alimony $ Investments $ Other $ Other $ I am married, and my spouse does not have any other sources of income. Another adult contributes to household income in the following amount: $. D. 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): Cash on hand $ Bank accounts $ Stocks/bonds $ Income tax refund $ Other assets (describe below): $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Rev091213taj IF YOU DO NOT HAVE ACCESS TO YOUR OWN OR YOUR SPOUSE'S INCOME OR ASSETS, EXPLAIN WHY. E. MONTHLY EXPENSES House Payment/Rent $ Utilities $ Telephone $ Groceries (after food stamps) $ Car Payment(s) $ Gasoline $ Insurance $ Child Care $ Student and Consumer Loans $ Court-ordered family support obligations $ Other court-ordered payments $ Medical expenses $ Other $ F. HOUSEHOLD I live at , and the head of the household is , Other than myself, the other members of the household are: Name Age Employment I Support American LegalNet, Inc. www.FormsWorkFlow.com Rev091213taj 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) Plaintiff Defendant (Pro Se) Pro Se (Street Address) (City, State, Zip Code) (Telephone) State of ) ) ss County of ) Signed and sworn to (or affirmed) before me on (date) by (name of applicant). Notary My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com