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Affidavit Of Indigency And Request For Relief From Fees And Costs - Massachusetts
| Affidavit Of Indigency And Request For Relief From Fees And Costs Form. This is a Massachusetts form and can be used in Housing Court Statewide . |
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COMMONWEALTH OF MASSACHUSETTS ________________,SS: HOUSING COURT DEPARTMENT ___________________ DIVISION No. ____________________________________ Plaintiff VS. ______________________________________ Defendant AFFIDAVIT OF INDIGENCY AND REQUEST FOR RELIEF FROM FEES AND COSTS The undersigned applicant states for an a ffidavit under penalties of perjury pursuant to Gen.L. c. 261, 27A-G as follows: 1. Applicant is indigent in that he/she: ____________ receives PUBLIC ASSISTANCE un der the Aid to Families with Dependent Children (AFDC), General Relief (GR), Veterans Benefits (VA), Supplemen tal Security Income (SSI), or Medicaid (MA) programs, (circle which programs), or; ____________ has INCOME, after taxes 125% or less of the current poverty threshold annually established by the U.S. Office of Management and Budget, cf. Gen.L. c. 221A, 1, or; ____________ is otherwise unable to pay the fees and costs of the proce eding, or is unable to do so wi thout deprivation of necessities of life, including food, shelter and clothing. 2. Applicant requests that th e following normal fees and costs (e.g., entry, filing fees, service of process costs, etc.) be waiv ed, substituted or paid for by the state: ______ ________________________________________________________________________ ____________________ Signed under the penalties of perjury: ____________________________________________ Name:_____________________________________ Address:__________________________________ ___________________________________________ DATE: ____________________________________ American LegalNet, Inc. www.USCourtForms.com
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