STATE OF WISCONSIN, CIRCUIT COURT, Amended COUNTY -vs- Petition for Waiver of Fees and Costs Affidavit of Indigency Case No. UNDER OATH, I STATE THAT because of poverty, I am unable to pay any filing and service fees, including the electronic filing fee, or , in this action, proceeding, or appeal, or to give security for those fees, and request waiver of those fees. I am attaching a copy of my pleading in this matter. 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 §59.53(21), Wis. Stats. Medical assistance. Food stamps/FoodShare. 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 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. Section 2. 1. I 2. I am am am not am not married. employed. Name of employer: every 2 weeks. per pay period. twice monthly. monthly. 3. I earn [Gross pay] $ weekly. My take-home pay [after taxes and deductions] is $ 4. I receive gross monthly income totaling the amount of $ from Pension Social security Unemployment compensation Disability Student loans/grants Other: 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: 7. My household consists of myself and Full name: Full name: Full name: Full name: Cash: $ Money owed me: $ Household furnishings: $ Equity in real estate: $ $ others: Relationship to me: Relationship to me: Relationship to me: Relationship to me: Under age 18 Under age 18 Under age 18 Under age 18 Yes Yes Yes Yes No No No No CV-410A, 02/16 Petition for Waiver of Fees and Costs - Affidavit of Indigency Page 1 of 2 §§757.675(3), 757.69(2m) and 814.29, Wisconsin Statutes American LegalNet, Inc. www.FormsWorkFlow.com This form shall not be modified. It may be supplemented with additional material. Petition for Waiver of Fees and Costs ­ Affidavit of Indigency Page 2 of 2 Case No. Full name: Wages Pension Disability Other: Relationship to me: Social security Relief funded under public assistance Student loans/grants Unemployment compensation Relief funded under §59.53(21), Wisconsin Statutes Under age 18 Yes No from 8. The other members of my household have gross monthly income totaling the amount of $ Food stamps/FoodShare Supplemental security income Support/maintenance 9. I have the following debts: a. Mortgage/Rent b. Auto loan c. Credit cards d. Other: e. Amount: $ $ $ $ $ Monthly Payment: 10. I have the following unusual expenses, other than ordinary living expenses: I understand that if my financial situation changes, I must notify the court immediately. State of County of Signature Notary Public/Court Official Name Printed or Typed Print or Type Name Subscribed and sworn to before me on Date of Birth My commission/term expires: Address Phone Number Date CV-410A, 02/16 Petition for Waiver of Fees and Costs - Affidavit of Indigency Page 2 of 2 §§757.675(3), 757.69(2m) and 814.29, Wisconsin Statutes American LegalNet, Inc. www.FormsWorkFlow.com This form shall not be modified. It may be supplemented with additional material.