New Mexico > Local District Court > 11th Judicial District > McKinley County
Motion For Free Process And Financial Affidavit - New Mexico
| Motion For Free Process And Financial Affidavit Form. This is a New Mexico form and can be used in McKinley County 11th Judicial District Local District Court . |
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ELEVENTH JUDICIAL DISTRICT COURT COUNTY OF McKINLEY STATE OF NEW MEXICO , Plaintiff, -vs- No. , Defendant. MOTION FOR FREE PROCESS AND FINANCIAL AFFIDAVIT STATE OF NEW MEXICO ) ) ss. COUNTY OF McKINLEY ) I, , being first duly sworn make the following statements in supportof my Motion for Free Process in the above entitled cause, pursuant to Section 34-6-27(B) N.M.S.A., 1978 (asamended): 1. No of people in household: . 2. Entire Family MONTHLY Income (including your spouses income): $ . (a) Sources of employment I am employed at: . and make $ per . My spouse is employed at and make $ per . (b) Public benefits as follows (i.e. AFDC, Food stamps, GA, SSI, Social Security, etc.) Other <<<<<<<<<********>>>>>>>>>>>>> 2 3.a) Allowable Expenses: Medical Expenses (not covered by insurance),Court-ordered support payments/alimony, Child-care payments (e.g. day-care) _________________________________________________________________. b) Other: (payroll garnishments, IRS claims, court ordered attorney fees or other court ordered payments and funeral expenses not covered by insurance). Must provide proof. 4. List any assets you have and their values (i.e. house, real estate, savings accounts, etc.) ___________________________________________________________ _________________________________________________________________ Total assets. Movant/Affiant SUBSCRIBED AND SWORN to before me this ____ day of , 20 . Notary Public My Commission expires: [******For clerk use only *************] Total income: (Monthly income X 12 months) $ Less total expenses (Monthly expenses X 12 months) $ Plus total assets: $ Net income: $ Indigency table: HOUSEHOLD SIZE (TOTAL) 1 2 3 4 5 6 7 8-------------------------------------------------------------------------------------------------------------------------------------------------------------NET INCOME $9675 $12,950 $16,225 $19,500 $22,775 $26,050 $29,350 $35,080 FOR EACH ADDITIONAL ADD: $2,975.00 The applicant is indigent The applicant is not indigent Signature of Screening Agent Date
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