STATE OF WISCONSIN SUPREME COURT ­ COURT OF APPEALS, DISTRICT Appellant or Petitioner: Please print or type. For Official Use -vsRespondent: Petition for Waiver of Fees/Costs Affidavit of Indigency Case No. Under oath I state that because of poverty, I am unable to pay the costs of this action, proceeding, or appeal, or to give security for those costs, and request waiver of those costs. I am attaching and incorporating into this affidavit a brief statement of the nature of the appeal or petition and the relief requested. Complete Section 1 if you receive aid from any of the programs listed. If you do not receive aid, complete section 2 only. Section 1. I currently receive: Supplemental security income Relief funded under Wis. Stats. §59.53(21) Medical assistance Food stamps/Food share Relief funded under public assistance Benefits for veterans under §45.40(1m) or 38 USC 501-562 Legal representation from a civil legal services program, a public defender program, or a volunteer attorney program based on indigency. Name of program: Other means-tested public assistance: My financial situation has has not changed since I became eligible for this program. If you checked the "has" box, and such changes would make you ineligible for the program(s) if you applied today, you must complete Section 2 below. Section 2. 1. I 2. I am am am not am not married. employed. Name of employer: every 2 weeks. twice monthly. per pay period. from: Unemployment compensation Other: monthly. 3. I earn [gross pay] $ weekly. My take-home pay [after taxes and deductions] is $ 4. I receive monthly income totaling the amount of $ Pension Social security Disability Student loans/grants 5. I have the following cash assets: Savings accounts: $ Checking accounts: $ 6. I have the following other assets: Vehicle-Yr./Make: $ Vehicle-Yr./Make: $ Other individual assets valued over $200 each: Cash: $ Money owed me: $ Household furnishings: $ Equity in real estate: $ $ Continued on Page 2 **File original with the Clerk of the Supreme Court ­ Court of Appeals.** AP-010, 03/15 Petition for Waiver of Fees/Costs- Affidavit of Indigency Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Wis. Stats. §814.29 Petition for Waiver of Fees/Costs- Affidavit of Indigency Page 2 of 2 Case No. Section 2 Continued: 7. My household consists of myself and Full name: Full name: Full name: Full name: Full name: others: Relationship to me: Relationship to me: Relationship to me: Relationship to me: Relationship to me: Under age 18 Under age 18 Under age 18 Under age 18 Under age 18 Yes Yes Yes Yes Yes No No No No No from: 8. The other members of my household have gross monthly income totaling the amount of $ Wages Pension Disability Other: Social security Relief funded under public assistance Student loans/grants Unemployment compensation Relief funded under §59.53(21), Wisconsin Statutes Food stamps/Food share Supplemental security income Support/maintenance 9. I do not receive income from any source because: 10. I have the following unusual debts or expenses, other than ordinary living expenses, on which I make monthly payments in the amount indicated: This can include attorneys fees or cash bail, if applicable. Type: Amount: Monthly Payment: $ $ $ $ $ $ $ $ $ $ 11. Anticipated transcript costs for this appeal (as represented to me by the court reporter): $ Note: You may attach a brief explanation of circumstances you feel the court should be made aware of in determining indigency. If you are a prisoner who is requesting permission to file an appeal or other proceeding in the supreme court or court of appeals without having to pay fees or costs, you are considered to have consented to the court ordering the prison to deduct the unpaid fees and costs from the prisoner's account if you lose the appeal or other proceeding. Wis. Stats. §814.29(3). State of County of Subscribed and sworn to before me on I understand that if my financial situation changes, I must notify the court immediately. Notary Public/Court Official Name Printed or Typed My commission expires: Affiant Date AP-010, 03/15 Petition for Waiver of Fees/Costs- Affidavit of Indigency Wis. Stats. §814.29 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com This form may be supplemented with additional material.