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Financial Affidavit And Application - Eligibility For Waiver Of Fees Costs Or Security In Civil Or Domestic Case SCA-CM201.03 - West Virginia
| Financial Affidavit And Application - Eligibility For Waiver Of Fees Costs Or Security In Civil Or Domestic Case Form. This is a West Virginia form and can be used in Fee Waiver General Court Statewide . |
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Financial Affidavit & Application, page 1 of 3 IN THE _________________ COURT OF ___________________ COUNTY, WEST VIRGINIA ______________________________ v. ___________________________________ Case No. ____________ Plaintiff or Petitioner Defendant or Respondent FINANCIAL AFFIDAVIT AND APPLICATION: ELIGIBILITY FOR WAIVER OF FEES, COSTS, OR SECURITY IN A CIVIL OR DOMESTIC CASE, OR FOR COSTS ASSOCIATED WITH REQUIRED POLYGRAPH EXAMINATION OR ELECTRONIC MONITORING A. Information for the Applicant: 1. You will be allowed to file and carry on your civil proceeding without giving security or paying fees or costs that would otherwise be required, if the court finds that you meet the official financial guidelines. 2. You must complete the affidavit for the court to determine if the costs of either a polygraph examination, required by W.V. Code 62-11D-2, or electronic monitoring, required by W.V. Code 62-11D-3, will be paid by the supervising entity. 3. You must file a separate affidavit and application anytime your financial situation no longer meets the official guidelines or anytime the court orders you to do so. 4. You must attach a copy of your most recent salary stub, W-2 form, or other financial documentation (with all Social Security Numbers and all dates of birth removed (you can black them out)) that verifies your income. Without the attached documentation, your application will be incomplete and not considered. 5. At any time you may request or the court may require review of your eligibility for a waiver; and at any time the court may require you to pay fees or costs previously waived or to pay future fees or costs. 6. When you sign this form, you will have to swear or affirm that you have completely and truthfully provided all information sought, to the best of your knowledge and ability. If you knowingly give any incomplete and/or false information, you may be prosecuted for the crime of false swearing. 7. The information you give in this form will be confidential only in a domestic violence or a divorce case. 8. Except for signatures, all information must be clearly printed. ================================================================================ B. Information about You and Your Case: 1a. Name: _________________________________ b. Telephone Number: _____________________ c. Address ________________________________ 2. Describe what is involved in your case:__________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ SCA-C&M201.03 (continued) American LegalNet, Inc. www.FormsWorkFlow.com Financial Affidavit & Application, page 2 of 3 3a. Do you have a lawyer?_______________ b. Have you paid or will you have to pay your lawyer? ________________ c. Will you have to pay your lawyer only if you win? _______________ 4. Check if seeking waiver for: G Cost of required polygraph examination (W.V. Code 62-11D-2); and/or G Cost of required electronic monitoring (W.V. Code 62-11D-3). ================================================================================ C. Information about Your Financial Situation: 1a. What is your current yearly net (take-home) income from all sources: Employer ________________ Second Job __________________ Self-Employment __________________ Public Assistance ______________ Food Stamps ______________ Unemployment __________________ Benefits __________________ Disability Benefits _________________ Social Security/SSI ___________ Alimony __________________ Pensions __________________ Rental Income _____________________ Interest ___________________ Dividends ___________________ Annuities ________________________ Odd Jobs _________________ Other (Specify:) _______________________________________________ YEARLY TOTAL: $____________________ Please remember to attach financial documents which verify this information. 1b. If your listed income is zero (0), please explain below and attach some verification (i.e. DHHR or food stamp information): _______________________________________________________________________________ __________________________________________________________________________________________ 2a. List the names and relationships to you of all the persons supported by this income, whether or not they are household members: provided, that these persons can be claimed as dependents on your federal tax return: __________________________________________________________________________________________ __________________________________________________________________________________________ b. What is the total number of dependents, including yourself? _______________ 3. How much money do you, individually or jointly, have in cash, checking and savings accounts, deposit certificates, and/or bonds (liquid assets)? $______________ 4a. List your regular monthly household debt-payment and other expenses: Mortgage/Rent _________________ Car payment ________________ Loan payments ______________ Credit card payments ________________ Other debt payments _____________________ Utilities _____________________ Cell phone __________________ Food _______________________ Child-care ________________ Child Support _______________________ Alimony ________________ Medical bills __________________ Other expenses (specify) ___________________________________ b. What is the total amount of these monthly expenses? $_____________________ 5a. List all cars, trucks, motorcycles, or recreational vehicles (all-terrain vehicles, motor homes, snowmobiles, boats), including their make, model, and year, that you own, individually or jointly: __________________________________________________________________________________________ __________________________________________________________________________________________ SCA-C&M201.03 (continued) American LegalNet, Inc. www.FormsWorkFlow.com Financial Affidavit & Application, page 3 of 3 b. What is the total value of these items less any amount owed? $_________________ 6a. List all real estate (houses, lots, land, rental property, other commercial property) that you, individually or jointly, own. __________________________________________________________________________________________ __________________________________________________________________________________________ b. What is the total value of these items less any amount owed? $ ___________________ 7. What wo
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