Affidavit {CV-191}

STATE OF MAINE SUPERIOR COURT , ss Docket No. Plaintiff v. Defendant I submit this affidavit in support of: My application to proceed without payment of fees Other: Name of person whose financial information appears on this affidavit: Mailing Address Date of Birth Home Phone Cell Phone Income: Employment. Employer is (name and address) Salary and wages (gross pay) $ every week biweekly month other OR Hourly wage $ and number of hours worked per week biweekly Benefits. (check all that apply) Unemployment Social Security TANF Alimony/child support other $ per week biweekly month other (if you get multiple benefits, please list the total amount of all the benefits per month) Assets: Cash bail I posted (1st party) in this or any other case $ Cash on hand $ Cash in the Bank $ Money owed to me $ Property worth more than $250 (include property owned alone or with any other person): House $ (amt. owed on house $ ) Vehicle $ Recreational Vehicles $ (boat, ATV, snowmobile, etc.) Other $ Expenses (Monthly) Mortgage $ Cable $ Rent $ Child Support $ Credit Card $ Cell Phone $ Utilities $ Loans $ Other AFFIDAVIT DISTRICT COURT Location Docket No. . . Work Phone month other Stocks $ Food $ Heat $ $ Check the following that apply I have (number) children who live with me I have (number) children for whom I pay support of $ per week I live alone with another who is my spouse friend parent(s) other: That person shares my living expenses and contributes $ per week bi-weekly bi-weekly month month other other I have read the above form, I understand it, and the answers to the questions are true. I understand that any false answers on this form may subject me to criminal prosecution. I understand and agree that further investigation may be conducted, if necessary, to verify the information I have provided. I also understand that I have a continuing obligation, personally and through counsel, to report to the court any changes in my employment or other financial circumstances. Date: Signature of (Plaintiff) (Defendant) Subscribed and sworn to before me. Notary, Clerk, Attorney, Judge/Justice CV-191, Rev. 11/13 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com