Property & Finances

a. General Information

I receive government assistance from the federal Supplemental Security Income (SSI) program.* Check this box if you get monthly SSI payments from the federal government. This is for people with low income who are disabled, blind, or elderly — not regular retirement or disability checks. I have attached the required proof that I participate in the Supplemental Security Income program. The proof shows my name as the benefit's recipient and the name of the agency that provides the benefit. Check this if you are including a document that proves you get SSI. The paper must show your name and the agency that pays you. If you attach this, you can skip the money questions in section 3. I receive government assistance from the state or federal program marked below: Check this box if you get help from one of the assistance programs listed below. Then mark which program applies to you. Temporary Assistance to Needy Families (TANF) Check this if you get TANF cash help for families with little or no income. Food Stamps Check this if you get Food Stamps (also called SNAP) to help buy food. I have attached the required proof that I participate in a government assistance program. The proof shows my name as the benefit's recipient and the name of the agency that provides the benefit. Check this if you are including a document that proves you get TANF or Food Stamps. The paper must show your name and the agency. If you attach this, you can skip the money questions in section 3. I receive legal assistance from a non-profit legal aid program. Check this box if a free or low-cost legal aid group is helping you with your case. I have attached the required proof that I receive legal assistance from a non-profit legal aid program. The proof shows my name as the recipient and the name of the legal aid provider that provides the assistance. Check this if you are including a document that proves a legal aid program is helping you. The paper must show your name and the provider's name. If you attach this, you can skip the money questions in section 3.

b. Possession & Access

My income is insufficient or is barely sufficient to meet the daily essentials of life, and includes no allotment that could be budgeted for the fees and costs that are required to gain access to the court. My gross income as computed on a monthly basis is 150% or less of the current federal poverty level. Check this box if you make very little money — barely enough to cover basic needs like food and housing — and your monthly income is at or below 150% of the federal poverty level. If you check this, you must fill out the money questions in section 3. I am permanently unable to pay. My income and liquid assets are insufficient or barely sufficient to meet the daily essentials of life and are unlikely to change in the foreseeable future. Check this box if you do not have enough money for basic needs and this is not likely to get better soon. I do not have the money to pay court filing fees and costs now. I can pay the filing fees and costs at a later date. Explain. Check this box if you cannot pay the fees right now but can pay them later. Explain. Tell the court why you can't pay now and when you expect to be able to pay.

c. Health & Medical Support

My income is greater than 150% of the poverty level, but I have proof of extraordinary expenses (including medical expenses and costs of care for elderly or disabled family members) or other expenses that reduce my gross monthly income to 150% or below the poverty level. Check this box if you earn more than the poverty level but have large expenses that bring your real income down to or below it. DESCRIPTION OF EXTRAORDINARY EXPENSES Describe one unusual expense, like a medical bill or care for a family member. AMOUNT Write the dollar amount for the expense you just described. DESCRIPTION OF EXTRAORDINARY EXPENSES Describe another unusual expense if you have one. AMOUNT Write the dollar amount for this expense. DESCRIPTION OF EXTRAORDINARY EXPENSES Describe a third unusual expense if you have one. AMOUNT Write the dollar amount for this expense. TOTAL EXTRAORDINARY EXPENSES Add up all the expense amounts above and write the total here.

d. Child Support

How many people, including yourself, do you support financially (including those you pay child support or spousal maintenance for)? Enter the total number of people you pay for, counting yourself. Include anyone you pay child or spousal support for. List relationship of those you support and check those living with you: Write how the first person is related to you, like child, parent, or spouse. List relationship of those you support and check those living with you: Check this box if this person lives in your home. List relationship of those you support and check those living with you: Write how the second person is related to you, like child, parent, or spouse. List relationship of those you support and check those living with you: Check this box if this person lives in your home. List relationship of those you support and check those living with you: Write how the third person is related to you, like child, parent, or spouse. List relationship of those you support and check those living with you: Check this box if this person lives in your home. List relationship of those you support and check those living with you: Write how the fourth person is related to you, like child, parent, or spouse. List relationship of those you support and check those living with you: Check this box if this person lives in your home. List relationship of those you support and check those living with you: Write how the fifth person is related to you, like child, parent, or spouse. List relationship of those you support and check those living with you: Check this box if this person lives in your home. List relationship of those you support and check those living with you: Write how the sixth person is related to you, like child, parent, or spouse. List relationship of those you support and check those living with you: Check this box if this person lives in your home. List relationship of those you support and check those living with you: Write how the seventh person is related to you, like child, parent, or spouse. List relationship of those you support and check those living with you: Check this box if this person lives in your home. List relationship of those you support and check those living with you: Write how the eighth person is related to you, like child, parent, or spouse. List relationship of those you support and check those living with you: Check this box if this person lives in your home. Do you have a job? Yes Check this box if you currently have a job. Do you have a job? No Check this box if you do not have a job right now. Employer name: Write the name of the company or person you work for. Leave blank if you have no job. Employer phone number: Write your employer's phone number. Leave blank if you have no job. What is your approximate gross monthly income (total income before deductions)? Enter your total monthly pay before any taxes or other money is taken out. What is your approximate monthly take home pay (total income after deductions)? Enter the amount you actually get to keep each month after taxes and deductions. social security Check this box if you get Social Security money. disability Check this box if you get disability payments. veteran's benefits Check this box if you get veteran's benefits. unemployment benefits Check this box if you get unemployment payments. spousal or child support Check this box if you receive child support or spousal support money. investments Check this box if you earn money from investments. other: Check this box if you have income from a source not listed here. other: Describe the other source of income you receive. What is your approximate total gross monthly income from these sources? Add up all the money you get each month from the sources you checked above. What is your spouse or domestic partner's approximate total gross monthly income from all sources readily available to you? Enter the total monthly income your spouse or partner gets from all sources you can use. Leave blank if this does not apply.

e. Possession & Access

What is the approximate total balance of bank and credit union accounts accessible without financial penalty? Enter the total money you have in bank and credit union accounts that you can take out without paying a fee.

f. Health & Medical Support

What are your average total monthly expenses, including rent/mortgage, utilities, vehicle/transportation, credit cards, insurance, medical/dental, child support, childcare, spousal maintenance, tuition, or other expenses? Add up everything you spend each month, like rent, food, bills, and other costs.