Motion And Affidavit In Support Of Request To Proceed As A Poor Person {GN-10}

IN THE _____ JUDICIAL CIRCUIT COURT, ____________________________, MISSOURI Judge or Division: Petitioner: Case Number: Petitioner's Address/Telephone: VS. Respondent: Respondent's Address/Telephone: (Date File Stamp) Motion and Affidavit in Support of Request to Proceed As a Poor Person Marital Status: If Married, Spouse's name: (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 __________________________ Total Monthly Income 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) _________________________ _________________________ _________________________ Total Assets $ ______________ $ ______________ $ ______________ $ ______________ Total Debts $ _______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ Number of dependents: Monthly Expenses Mortgage Utilities Food Payment on debts & credit cards Child Support Maintenance Medical expenses to be considered ____________________________ Total Monthly Expenses Debts Home loan balance Automobile loan(s) Credit card balance(s) Other debts to be considered ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ Rent Payment $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ I swear/affirm under penalty of perjury that these facts are true to my best knowledge and belief. _________________________________ Date OSCA (07-15) GN10 ________________________________________ Your Signature 1 of 1 Rule 77.03, Section 514.040 RSMo www.FormsWorkflow.com