Motion And Affidavit In Support Of Request To Proceed As A Poor Person

IN THE ____ JUDICIAL CIRCUIT COURT, ______________________________, MISSOURI Judge or Division: Case Number: Petitioner: Petitioner's Address/Telephone: SSN: VS. Respondent: Respondent's Address/Telephone: SSN: (Date File Stamp) Motion and Affidavit in Support of Request to Proceed As a Poor Person Marital Status: If Married, Spouse's name: Number of dependents: (Include Spouse's Income and Expenses if Married) Monthly Income Gross salary (before deductions) Public assistance Retirement/Pension Social Security Child Support Maintenance Other income to be considered __________________________ Monthly Expenses Rent Payment Mortgage Utilities Food Payment on debts & credit cards Child Support Maintenance Medical expenses to be considered ____________________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ Total Monthly Income $ _________________ Total Monthly Expenses $ _______________ Assets Cash on Hand Bank Accounts: Checking Savings Approximate value of home And/or other real estate Approximate value of automobile(s) (1) yr/make ______________ (2) yr/make ______________ Approximate value of personal Possessions (list) _________________________ _________________________ _________________________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ Debts Home loan balance Automobile loan(s) Credit card balance(s) Other debts to be considered ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ ______________ $ ______________ $ ______________ Total Assets $ ______________ Total Debts $ _______________ OSCA (10-06) GN10 1 of 2 Rule 77.03, Section 514.040 RSMo American LegalNet, Inc. www.FormsWorkFlow.com I swear/affirm under penalty of perjury that these facts are true to my best knowledge and belief. __________________________________________ Date _____________________________________________ Your Signature Order to Proceed as a Poor Person The Court, having considered the Motion and Affidavit in Support of Request to Proceed as a Poor Person, finds that ____________________________________ is without sufficient funds or assets with which to pay the advance deposit for costs in this action and, therefore, is granted leave to proceed as a poor person and the required advanced deposit for costs is waived. The Court, having considered the Motion and Affidavit in Support of Request to Proceed as a Poor Person, finds that _________________________________________ has sufficient funds or assets with which to pay the advance deposit for costs in this action, and therefore, the Motion is denied. __________________________________________ Date _____________________________________________ Commissioner/Judge OSCA (10-06) GN10 2 of 2 Rule 77.03, Section 514.040 RSMo American LegalNet, Inc. www.FormsWorkFlow.com