Motion, Affidavit and Order in Forma Pauperis - Grant County ...
Motion, Affidavit and Order in Forma Pauperis - Grant County ...
Motion, Affidavit and Order in Forma Pauperis - Grant County ...
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
IN THE DISTRICT COURT OF THE STATE OF WASHINGTON<br />
IN AND FOR THE COUNTY OF GRANT<br />
) CASE NUMBER<br />
STATE OF WASHINGTON )<br />
(Pla<strong>in</strong>tiff) ) MOTION, AFFIDAVIT<br />
) AND ORDER<br />
) IN FORMA PAUPERIS<br />
______________________ _____ )<br />
(Defendant)<br />
____________________<br />
I. MOTION<br />
1.1 I, _____________________________________, Petitioner here<strong>in</strong>, move the Court<br />
for an <strong>Order</strong> authoriz<strong>in</strong>g me to proceed In <strong>Forma</strong> <strong>Pauperis</strong> (at public expense) <strong>and</strong><br />
direction the Clerk of the Court of Limited Jurisdiction, without payment of a<br />
fil<strong>in</strong>g fee.<br />
1.2 The follow<strong>in</strong>g affidavit, together with files <strong>and</strong> records here<strong>in</strong>, is made <strong>in</strong> support<br />
of this <strong>Motion</strong>.<br />
1.3 I underst<strong>and</strong> that any statement that I make <strong>in</strong> the follow<strong>in</strong>g affidavit may be used<br />
aga<strong>in</strong>st me.<br />
Dated ___________________ Signature _________________________________<br />
II.<br />
<strong>Affidavit</strong><br />
2.1 I, ___________________________________, am Petitioner/Appellant here<strong>in</strong>.<br />
2.2 Appeal from Court of Limited Jurisdiction.<br />
2.3 I am f<strong>in</strong>ancially unable to pay a fil<strong>in</strong>g fee without caus<strong>in</strong>g substantial hardship to<br />
myself or family.<br />
2.4 I declare under penalty of perjury that the follow<strong>in</strong>g <strong>in</strong>formation is true <strong>and</strong> is<br />
<strong>in</strong>tended to be relied upon by the court <strong>in</strong> determ<strong>in</strong><strong>in</strong>g my eligibility for fil<strong>in</strong>g at<br />
public expense.<br />
MOTION, AFFIDAVIT AND ORDER IN FORMA PAUPERIS<br />
GCD IFP 2-20-07<br />
1
III.<br />
FINANCIAL STATEMENT<br />
3.1 GENERAL INFORMATION<br />
(a) Name _________________________ (c) Social Security___________________<br />
(b)Address________________________ (e) Date of Birth ___________________<br />
_______________________________<br />
(City)<br />
(StateZip Code)<br />
(f1) Name <strong>and</strong> Address of Your Employer__________________________________<br />
_____________________________________________________________________<br />
Length of Employment ____________ Occupation ___________________________<br />
(f2) Name <strong>and</strong> Address of Spouse’s Employer _______________________________<br />
_____________________________________________________________________<br />
Length of Employment ____________ Occupation ___________________________<br />
3.2. INCOME AND ASSETS EXPENSES AND DEBTS<br />
(a) Personal gross monthly <strong>in</strong>come____________ (a) Monthly liv<strong>in</strong>g expense (itemize)<br />
(b) Spouse’s gross monthly <strong>in</strong>come____________ Rent or mortgage______________<br />
(c) Other <strong>in</strong>come___________________________ Food _______________________<br />
(d) Cash on h<strong>and</strong> __________________________ Utilities ____________________<br />
(e) Home (cash value less amt ow<strong>in</strong>g)___________ Transportation ________________<br />
(f) Auto(cash value less amt, ow<strong>in</strong>g) ___________ Installment payments __________<br />
(g) Furniture (approx value)__________________ Medical & Dental_____________<br />
(Ii) Notes, mortgage:, trust, deeds _____________ Insurance ___________________<br />
(i) Stocks, bonds (approx. value) ______________ Other ______________________<br />
(j) Persons whom you f<strong>in</strong>ancially support (b) DEBTS Amount ow<strong>in</strong>g<br />
Spouse [ ]<br />
___________________________<br />
Children [ ] ages __________<br />
___________________________<br />
Other [ ]<br />
___________________________<br />
___________________________<br />
___________________________<br />
Total______________<br />
Total ______________________<br />
3.3 I certify under penalty of perjury under the Laws of the State of Wash<strong>in</strong>gton that I have<br />
read the forego<strong>in</strong>g statements <strong>in</strong> the <strong>Affidavit</strong>, known the contents thereof, <strong>and</strong> believe them<br />
to be true <strong>and</strong> correct.<br />
Dated this _______________day of______________________________________________<br />
______________________________________ ___________________________________<br />
Signature<br />
Signature<br />
MOTION, AFFIDAVIT AND ORDER IN FORMA PAUPERIS<br />
GCD IFP 2-20-07<br />
2
It is hereby ordered that:<br />
ORDER<br />
[ ] The petitioner is permitted to proceed without payment of the fil<strong>in</strong>g fee.<br />
[ ] The petition is denied.<br />
Dated this ______________day of___________________________________________<br />
_________________________________________<br />
Judge/Court Commissioner<br />
MOTION, AFFIDAVIT AND ORDER IN FORMA PAUPERIS<br />
GCD IFP 2-20-07<br />
3