CV- Affidavit of Indigency 247814.29, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY - vs - Waiver of Prepayment of Fees/Costs Affidavit of Indigency Case No. (The prisoner must provide the following to the Clerk of Court at the time of filing: The original and one copy of this affidavit and attachments. Sufficient copies of the pleadings for potential service on all named defendants.) UNDER OATH I STATE: 1. I am unable to pay the costs of this action, special proceeding or appeal or to give security for those costs, and request waiver of prepayment of those costs because of poverty. 2. I have not had three or more appeals, writs of error, actions or special proceedings dismissed by a state or federal court for any of the reasons listed in 247802.05(3)(b)1-4, Wisconsin Statutes. Attached is the original Wisconsin Department of Justice certification (form DJ-LS-22 containing the raised seal) dated within 30 days of the date of this petition concerning the number of appeals, writs of error, actions or special proceedings dismissed by a state or federal court. 3. I have attached and incorporated into this affidavit: The original pleading in this matter. [If this proceeding is related to prison or jail conditions]: Written documentation of exhaustion of all available administrative remedies, including copies of all written materials: I provided to the administrative agency as part of the administrative proceeding; the administrative agency provided to me related to the administrative proceeding; and, included as part of any administrative appeal. A certified copy of my prison trust fund account for the six months preceding the date of this petition. My authorization to the agency having custody of my prison trust fund account (on DOC form 1930 provided by the Wisconsin Department of Corrections), to forward payments from my account to the clerk of court each time the amount in the account exceeds $10, until the costs and fees are paid in full. 4. I have have not committed an offense on or after September 1, 1998. (An offense is defined in 247165.83(1)(c), Wisconsin Statutes, as an act which is a felony, misdemeanor, or violation of a city, county, village, or town ordinance. 5. I am am not employed. Name of employer: 6. I earn $ gross weekly. every two weeks. twice monthly. monthly. 7. I have received or been entitled to receive money from the following sources within the past 12 months (list total amount): pension, annuities or life insurance payments: ............. $ disability or worker's compensation payments: ............. $ gifts, loans or inheritances: ...................................... $ rent payments, interest or dividends: ............................ $ business, profession or self employment: ..................... $ other: ...................................... $ 8. I have the following cash assets: savings accounts: .................. $ checking accounts: ................ $ cash: .............................. $ money owed me: ................... $ American LegalNet, Inc. www.FormsWorkFlow.com CV- Affidavit of Indigency 247814.29, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 any other cash assets: .......... $ 9. I have the following other assets (list value): real estate: ................................................... $ stocks, bonds, securities and financial instruments: ................. $ automobiles: ................................................... $ computers, audio-visual equipment, other personal property: ... $ jewelry, antiques, objects of art or other valuable property : .... $ 10. I have not transferred any funds or other assets in the past 12 months except as follows (describe any transfers): 11. I have not assigned my rights to any funds or other assets since first incarcerated except as follows (describe any assignments): 12. I have the following legal obligations: Obligation Amount Actually Paid Per Month Amount Actually Paid in Last Six Months Child Support $ $ Restitution $ $ Fines/Costs $ $ Other: $ $ 13. My spouse is is not employed. Name of employer: 14. My spouse earns $ gross weekly. every two weeks twice monthly monthly. 15. My spouse receives monthly income totaling the amount of $ from: Pension Social Security Unemployment compensation Disability Student loans/grants Other: 16. I have the following miscellaneous expenses: I understand that if my financial situation changes, I must notify the court immediately. State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Petitioner Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com