MOTION TO FILE WITHOUT PAYMENT SUPPORTING FINANCIAL AFFIDAVIT, AND SUPPORTING DOCUMENTATION REQUESTED
General Information
It is important that you accurately complete all sections of this form as appropriate based on your personal circumstances. If a section does not apply, please write N/A.
A. Gross Monthly Income. Includes income from all members of the household who contribute monetarily to the common support of the household.
wIncome categories to include:
Wages, including tips, salaries, commissions, payments received as an independent contractor for labor or services, bonuses, dividends, severance pay, pensions, retirement benefits, royalties, interest/investment earnings, trust income, annuities, capital gains, unemployment benefits, Social Security Disability (SSD), Social Security Supplemental Income (SSI), Workman’s Compensation Benefits, and alimony.
Note: Income from roommates should not be considered if such income is not commingled in accounts or otherwise combined with the applicant’s income in a fashion which would allow the applicant proprietary rights to the roommate’s income.
wIncome categories do not include:
TANF payments, food stamps, subsidized housing assistance, veteran’s benefits earned from a disability, child support payments, or other public assistance programs.
B.Liquid Assets. Includes cash on hand or in accounts, stocks bonds, certificates of deposit, equity, and personal property or investments which could readily be converted into cash without jeopardizing the applicant’s ability to maintain home and employment.
Expenses. Nonessential items such as cable television, club memberships, entertainment, dining out, alcohol, cigarettes, etc., shall not be included. Allowable expense categories are listed on JDF 205.
If you are applying to have your filing fee waived you may be asked to
supply:
•Copies of the previous three months bank statements, including checking and savings. DO NOT provide originals.
•Copies of the previous three months pay stubs and/or proof of income must be included. DO NOT provide originals.