COURT USE ONLY COURT USE ONLY COURT USE ONLY FOR NOTARY PUBLIC222S USE ONLY: State of ............................................................................................ [ ] City [ ] County of ............................................................................................. Acknowledged, subscribed and sworn to before me this ...................... day of ........................................................................... , 20 ................. ......................................................................................... NOTARY REGISRATION NUMBER NOTARY PUBLIC (My commission expires: ................................ ......................... ) FINANCIAL STATEMENT FOR APPLICATION TO PROCEED Case No. ............................................................. IN CUSTODY/VISITATION CASE WITHOUT FILING FEES OR FOR ASSESSMENT OF GUARDIAN AD LITEM COSTS Commonwealth of Virginia VA. CODE 247 19.2-159 I am requesting that the court find that I am unable to pay filing fees or costs pursuant to Va. Code 247 16.1-267(C) or 247 16.1-69.48:5. The following information is true and provided in support of my request: [ ] I currently receive the following type(s) of public assistance: [ ] TANF $ ........................................................... [ ] Medicaid [ ] Supplemental Security Income $ ................................................................ [ ] SNAP (food stamps) $ .......................................................................... [ ] Other (specify type and amount) .................................................................................................................................................................................................... Names and address of employer(s) for myself and for my spouse (if my household member): Self ............................................................................................................................................................................................................................................................................... Spouse (not applicable if alleged victim) ..................................................................................................................................................................................................... NET INCOME: Self Spouse Pay period (weekly, every second week, twice monthly, monthly) ................................ .......................... ........................... Net take home pay (salary/wages, minus deductions required by law) ......................... $ ....................... ........................... Other income sources (please specify) ...................................................................................................................................................................... .......................... $ ....................... TOTAL INCOME .......................... + ........................... = A ASSETS: Cash on hand ......................................................................................................................................... $ ....................... ........................... Bank Accounts at: ............................................................................................................................... $ ....................... ........................... Any other assets: (please specify) ............................................................................................................. with a value of .............................. $ ....................... ........................... Real estate 226 $ $ ....................... ........................... NET VALUE with a value of .............................. $ ....................... ........................... YEAR AND MAKE Motor Vehicles: with a value of .............................. $ ....................... ........................... YEAR AND MAKE Other Personal Property: (describe) ............................................................................................. $ ....................... ........................ .TOTAL ASSETS $ ....................... + ........................... = B EXCEPTIONAL EXPENSES (Total Exceptional Expenses of Family) Medical Expenses (list only unusual and continuing expenses) .................................................................. $ .............................. Court-ordered support payments/alimony ............................................................................................................ $ .............................. [ ] deducted from paycheck [ ] not deducted from paycheck Child-care payments (e.g. day care) ....................................................................................................................... $ .............................. Other (describe): ............................................................................................................................................................. $ .............................. [ ] I am a Virginia resident. TOTAL EXPENSES $ .............................. = C [ ] I am not a Virginia resident. COLUMN 223A224 plus COLUMN 223B224 minus COLUMN 223C224 equals available funds = I hereby state that the above information is correct to the best of my knowledge. ............................................................... ..................................................................................... DATE SIGNATURE PRINTED NAME Sworn/affirmed and signed before me this day. ............................................................... DATE SIGNATURE TITLE ORDER (if applicable) The request to proceed without payment of filing fees is [ ] granted [ ] denied. If this application is denied, the case will not be set for hearing until the applicable fee is paid to the clerk. ................................................................................. DATE JUDGE ................. Number in household I have financial responsibility for, including myself. FORM DC-606 MASTER 07/17 American LegalNet, Inc. www.FormsWorkFlow.com