New Mexico > Local District Court > 6th Judicial District
Financial Affidavit Application To Proceed In Forma Pauperis 1.02 - New Mexico
| Financial Affidavit Application To Proceed In Forma Pauperis Form. This is a New Mexico form and can be used in 6th Judicial District Local District Court . |
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Sixth Judicial District Supreme Court Approved LR6-Form 1.02 June 29, 2000 1 LR6-Form 1.02 2 3 STATE OF NEW MEXICO 4 COUNTY OF ___________________________ 5 SIXTH JUDICIAL DISTRICT COURT 6 7 _____________________________, Petitioner, 8 9 v. No. ___________10 11 _____________________________, Respondent 12 13 FINANCIAL AFFIDAVIT APPLICATION TO PROCEED 14 IN FORMA PAUPERIS 15 16 Pursuant to LR6-108 NMRA, I ________________________ 17 (name of party) , request that the court enter an order 18 permitting me to file this case without prepayment of fees 19 and costs and state upon my oath or affirmation the 20 following statement regarding my financial, marital and 21 employment status: 22 A. Background and Residence 23 1. Full name: ________________________________ 24 2. Age: ________________________________ 25 3. Sex: ________________________________ 26 4. Present address: ___________________________ 27 _____________________________________________ 28 5. How long at this address? _________________ 29 6. Phone number: ____________________ 30 7. Married ___ Single ___ Divorced ___ 31 Separated ___ 32 8. Number of dependents: _____________________33 9. Ages of children living with you: ___________ <<<<<<<<<********>>>>>>>>>>>>> 2 Sixth Judicial District Supreme Court Approved LR6-Form 1.02 June 29, 2000 1 ___________________________________________ 2 10. List name and relationship of other 3 dependents living with you: ________________ 4 ____________________________________________ 5 11. List any dependents in items 7 and 8 6 depending on you for your support: 7 ________________________________ 8 B. Employment and income 9 1. Are you employed? __________ 10 Are you self-employed? ______________11 2. Name and address of employer: 12 ________________________________ 13 ________________________________ 14 3. Position: ______________________ 15 Salary per month: _________________16 4. If self-employed, nature of business:17 ____________________________________ 18 5. Income previous month from self-employment:19 $_____________________. 20 6. If unemployed, how long since last job or21 self-employment? __________________________22 7. Any other income including, but not limited23 to, disability pay, workmans compensation,24 social security, pension, interest, note and25 loan repayments, dividends, trust funds and 2 <<<<<<<<<********>>>>>>>>>>>>> 3 Sixth Judicial District Supreme Court Approved LR6-Form 1.02 June 29, 2000 1 unemployment compensation? [ ] Yes [ ] No. 2 8. If the answer to 7 is yes, list each source 3 and amount per month from each source: 4 __________________ $______________________ 5 __________________ $______________________ 6 9. Total monthly net income: _______________ 7 ______________________________________. 8 C. Assets 9 1. Do you own any real estate? 10 Yes [ ] No [ ] 11 a. Description __________________________12 b. Location _____________________________13 c. Estimated present value ______________ 14 d. Estimate outstanding mortgages or 15 contracts on property _______________16 _____________________________________ 17 e. Payments per month: ________________ 18 2. Do you own any automobiles? Yes [ ] No [ ] 19 a. Make ________ Model _____ Year _____ 20 b. Present Value: ________ 21 Total amount owed $________________ 22 c. Monthly payments _________________ 23 3. Do you have any stocks or bonds? 24 Yes [ ] No [ ] 25 a. Describe ________________________ 3 <<<<<<<<<********>>>>>>>>>>>>> 4 Sixth Judicial District Supreme Court Approved LR6-Form 1.02 June 29, 2000 1 b. Present value: ________________ 2 4. Do you have any cash in the bank? 3 Yes [ ] No [ ] 4 a. If so, indicate amount : _______________ 5 5. Do you have any cash in a savings and loan 6 association? Yes [ ] No [ ] 7 6. Do you have any other assets not listed above 8 excluding household furnishings and clothing? 9 Yes [ ] No [ ] 10 a. If so, describe and give value: 11 ___________________________________ 12 D. Debts and other obligations 13 1. Rent: $_____________ per month. 14 2. Utilities: $____________ per month. 15 3. Creditors: 16 List: Total Due: Monthly Payment17 ________________ ____________ _______________18 ________________ ____________ _______________19 ________________ ____________ _______________20 ________________ ____________ _______________21 4. Total monthly payments: $______________22 E. I have no information regarding my spouses income and 23 or my spouse lives out of state. 24 OR 25 I have the following information regarding my 4 <<<<<<<<<********>>>>>>>>>>>>> 5 Sixth Judicial District Supreme Court Approved LR6-Form 1.02 June 29, 2000 1 spouse: 2 1. Address: ________________________________ 3 __________________________________________ 4 2. Employers address : _______________________ 5 ___________________________________________ 6 3. Income: $_________ (monthly weekly biweekly) 7 4. Resource: 8 Cash (savings, etc): ______________________ 9 ___________________________________________10 Social Security: $_________________________11 Unemployment compensation: $_______________12 Other income : $_________________13 Describe: _____________________________14 ________________________________________15 5. Debts: 16 Mortgage or rent: $_________________________17 Utilities: $________________________________18 Other creditors: $________________________19 ____________________________________________20 ____________________________________________21 I [do] [do not] have access to my spouses resources or 22 income. 23 _____________________________24 Petitioner 25 26 SUBSCRIBED AND SWORN TO before me this ____ day of 27 _______________, _____, by ______________________________. 28 5 <<<<<<<<<********>>>>>>>>>>>>> 6 Sixth Judicial District Supreme Court Approved LR6-Form 1.02 June 29, 20001 _____________________________2 Notary Public3 4 My Commission Expires: 5 ______________________ 6 7 8 [Approved, effective October 2, 2000.] 9 6
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