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 ...
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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 />
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