I, 	, having been duly sworn according to law, make oath that because of my poverty, I am unable to bear the expenses of this case and that I am justly entitled to the relief sought to the best of my belief.  The following facts support my poverty.

1.  Full Name:	 			2.  Address:		 
3.  Telephone Number:   		4.  Date of Birth:  

5.  Names and Ages of All Dependents:
  		Relationship:  		
 	  Relationship: 	
	  Relationship: 	
	  Relationship:  	

6.  I am employed by:  	 
	My employer’s address is: 	
	My employer’s phone number is: 	

7.  My Present income, after federal income and social security taxes, are deducted, is: $ 	
8.  I receive or expect to receive money from the following sources:
	
AFDC	$ 	 	per month 	beginning 	
SSI		$ 	 	per month	beginning 	
Retirement		$	 	per month	beginning 	
Disability		$ 		per month 	beginning 	
Unemployment		$ 	 	per month 	beginning 	
Worker’s Compensation	$ 		per month	beginning  	
Other	$		per month	beginning  	

9.  My expenses are:
		Rent/House Payment	$		per month	Medical/Dental	$	 	per month
		Groceries	$		per month	Telephone	$		per month
		Electricity	$		per month	School Supplies	$		per month
		Water	$		per month	Clothing	$		per month
		Gas	$		per month	Child Care or	$		per month
		Transportation	$		per month	   Court Ordered Child Support 
					Other	$		per month

10.  Assets:
		Automobile	$	(FMV)		
		Checking/Savings Account	$		
		House	$	(FMV)		
		Other	$	

11.  My debts are:
		Amount Owed		To Whom

	I hereby declare under the penalty of perjury that the foregoing answers are true, correct, and complete and that I am financially unable to pay the costs of this action.

			PLAINTIFF 

ORDER ALLOWING FILING ON PAUPER’S OATH

	It appears based upon the Affidavit of Indigency filed in this cause and after due inquiry made that the Plaintiff is an indigent person and is qualified to file case upon a pauper’s oath.

It is so ordered this the   	day of 	, 20	 
		
		JUDGE

DETERMINATION OF NONINDIGENCY 

	It appearing based upon the Affidavit of Indigency filed in this cause and after due inquiry made that the Plaintiff is not an indigent person because 	.

	IT IS ORDERED AND AJUDGED that the Plaintiff does not qualify for filing this case on a pauper’s oath.
	   This the 	 day of 	, 20 	.

	JUDGE

NOTICE:  If the judge determines that based upon your affidavit you are not eligible to proceed under a pauper’s oath, you have the right to a hearing before the judge or, in those cases that can be appealed to Circuit Court, a hearing before the Circuit Court judge.