Total Monthly Expenses (add all Social Security Benefits (regular or numbers above together) disability) Child Support Public Assistance (TANF, Medicaid, other) Income (Monthly) Monthly Amount Cash Gifts Take Home Pay from Job Other Income Spouse’s Take Home Pay from Job Investment Income (Stocks, Bonds, Retirement, etc) Rental Income Total Monthly Income (add all numbers above together Unemployment ASSETS Asset Value Place of Residence ________Rent ___________ Own $ Real Property owned such a land or rental properties. List the addresses $ $ $ Automobiles Make Model Year $ Make Model Year $ Please deduct amounts owed from the value Stocks and Bonds (provide a description) $ $ Other Property of value: (jewelry, equipment, watercrafts, etc) $ $ Bank Accounts: Name Type of Account Balance $ Name Type of Account Balance $ Other Assets: Assets Total Value (add all numbers above together CERTIFICATION I hereby certify, under penalty of perjury, that the above information is correct to the best of my knowledge. I understand that I have been charged with _____________________________________ and my amount due is _________________________. I am requesting the following: ________ That I be allowed to perform community service in lieu of paying my fines and court costs due to indigence.
Total Monthly Expenses (add all numbers above together) Income (Monthly) Monthly Amount Take Home Pay from Job Spouse’s Take Home Pay from Job Investment Income (Stocks, Bonds, Retirement, etc) Rental Income Unemployment Social Security Benefits (regular or disability) Child Support Public Assistance (TANF, Medicaid, other) Cash Gifts Other Income Total Monthly Income (add all numbers above together ASSETS Asset Value Place of Residence ________Rent ___________ Own $ Real Property owned such a land or rental properties. List the addresses $ $ $ Automobiles Make Model Year Make Model Year Please deduct amounts owed from the value $ $ Stocks and Bonds (provide a description) $ $ Other Property of value: (jewelry, equipment, watercrafts, etc) $ $ Bank Accounts: Name Type of Account Name Type of Account Balance $ Balance $ Other Assets: Assets Total Value (add all numbers above together CERTIFICATION I hereby certify, under penalty of perjury, that the above information is correct to the best of my knowledge. I understand that I have been charged with _____________________________________ and my amount due is _________________________. I am requesting the following: ________ That I be allowed to perform community service in lieu of paying my fines and court costs due to indigence.
AFFIDAVIT%20OF%20INDIGENCE.docx