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This is a New Mexico form that can be used for Domestic within Local District Court, 11th Judicial District, San Juan County.
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APPLICATION FOR FREE PROCESS PROOF OF INCOME You must provide your pay stubs and/or proof of public assistance when you apply for free process. If you have no income and are being supported by another person, you must provide that person's pay stubs or proof of public assistance. 1 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF NEW MEXICO COUNTY OF SAN JUAN ELEVENTH JUDICIAL DISTRICT COURT _______________________________ Plaintiff/Petitioner, v. No. D-1116-_____________________ _______________________________ Defendant/Respondent. APPLICATION FOR FREE PROCESS AND AFFIDAVIT OF INDIGENCY I request that the Court enter an order permitting me to file this case without prepayment of fees and costs and give upon my oath or affirmation the following statement. My marital status is: Single ____ Married ____ Divorced ___ Separated ____ Widowed____ I request interpretation services: ___ yes ___no (If yes, please describe what you need: ___________________________________________________________________________ INFORMATION ABOUT MY FINANCES (check all that apply to you and fill in the blanks): A. PUBLIC ASSISTANCE ___ I do not receive public assistance (If you check this blank, go directly to Section B EMPLOYMENT/UNEMPLOYMENT). ___ I currently receive the following public assistance in ________________County (please check all applicable public assistance programs): ___Temporary Assistance for Needy Families (TANF) ___Food Stamps ___Medicaid ___General Assistance (GA) ___Supplemental Security Income (SSI) ___Social Security Disability Income (SSDI) ___Public Housing ___Disability Security Income (DSI) ___Department of Health Case Management Services (DHMS) ___Other (please describe _____________________________) 2 American LegalNet, Inc. www.FormsWorkFlow.com B. EMPLOYMENT/UNEMPLOYMENT ___I am currently unemployed and have been unemployed for ___ months in the past year. I am unemployed because _____________________________________________________. ___ I receive unemployment benefits in the amount of $___________per month. ___ I have no income because I am unemployed. ___I am employed. My employer's name, address and phone number is: ________________________________________________________ ________________________________________________________ ________________________________________________________ I am paid weekly ___ every other week ___ twice a month ___ once a month ___. When I am paid, my net take-home pay minus deductions required by law like state and federal tax withholding and FICA is $______________. ____I am married, and my spouse is unemployed and has been unemployed for ____ months in the past year because ________________________________________________________________. ___ My spouse receives unemployment benefits in the amount of $_________per month. ___I am married, and my spouse is employed. My spouse's employer's name, address and phone number is: ________________________________________________________ ________________________________________________________ ________________________________________________________ My spouse is paid weekly ___ every other week ___ twice a month ___ once a month ___. When my spouse is paid his or her net take home pay minus deductions required by law like state and federal tax withholding and FICA is $______________. C. OTHER SOURCES OF INCOME ___I have income from another source not mentioned above. _____ Child Support $_________ _____ Alimony $_________ _____ Investments $_________ _____ Community property from my spouse $_________ _____ Other _________________________ $_________ ____I do not have any other sources of income. ___I am married, and my spouse has income from another source not mentioned above. _____ Child Support $_________ _____ Alimony $_________ _____ Investments $_________ 3 American LegalNet, Inc. www.FormsWorkFlow.com _____ Other _________________________ $_________ _____ Other _________________________ $_________ ____I am married, and my spouse does not have any other sources of income. D. OTHER ASSETS (Please list other assets owned by you or your spouse that can be turned into cash. Do not include money you have in retirement accounts): Cash on hand $__________ Bank accounts $__________ Income tax refund $__________ Other assets (describe below): ____________________ $__________ ____________________ $__________ IF YOU DO NOT HAVE ACCESS TO YOUR OWN OR YOUR SPOUSE'S INCOME OR ASSETS, EXPLAIN WHY. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________________________ E. MONTHLY EXPENSES House Payment/Rent $__________ Utilities $__________ Telephone $__________ Groceries (after food stamps) $__________ Car Payment(s) $__________ Gasoline $__________ Insurance $__________ Child Care $__________ Student and Consumer Loans $__________ Court-ordered family support obligations $__________ Other court-ordered payments $__________ Medical expenses $__________ Other____________________ $__________ F. HOUSEHOLD I live at _____________________________________________________________________, and the head of the household is __________________________________________________. Other than myself, the other members of the household are: 4 American LegalNet, Inc. www.FormsWorkFlow.com Name _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ Age _________ _________ _________ _________ _________ _________ _________ Employment _______________ _______________ _______________ _______________ _______________ _______________ _______________ I Support ( ( ( ( ( ( ( ) ) ) ) ) ) ) This statement is made under oath. I hereby state that the above information regarding my financial condition is correct to the best of my knowledge. I hereby authorize the Court to obtain information from financial institutions, employers, relatives, the federal internal revenue service and other state agencies. If at any time the Court discovers that information in this application for free process was false, misleading, inaccurate, or incomplete at the time the application was submitted, the Court may require me to pay for any costs or fee