Financial Statement Affidavit

IN THE SUPREME COURT OF THE STATE OF ALASKA FINANCIAL STATEMENT AFFIDAVIT For use with a motion to waive filing fee, when the basis for the motion is inability to pay, a motion to appeal at public expense, or an application for an exemption from filing fee under AS 9.19.010. 1. Appellant's (or Petitioner's) Name: 2. Appellant's Telephone: 3. Case No. (for court system use) 4. Appellant's Residence Address: ___________________________________________________________ _____________________________________________________________________________________ 5. Appellant's Mailing Address: _____________________________________________________________ _____________________________________________________________________________________ 6. a. GMarried GSingle GDivorced GSeparated GWidowed 7. a. Are your working now? GYes GNo b. How long? b. If not, date last worked: 8. LIST ALL EMPLOYERS FOR THE LAST 12 MONTHS a. 1) Present or Former Employer:_____________________________________________________________ 2) Address & Telephone:__________________________________________________________________ 3) Job Title:_______________________________________ 4) Salary: $__________________per_______ 5) FROM__________________ TO ___________________ 5) No. Hours Per Week__________________ (Month and Year) (Month and Year) b. 1) Present or Past Employer:_______________________________________________________________ 2) Address & Telephone:__________________________________________________________________ 3) Job Title:_______________________________________ 4) Salary: $__________________per_______ 5) FROM__________________ TO ___________________ 5) No. Hours Per Week__________________ (Month and Year) (Month and Year) 9. a. Do you belong to a Labor Union? GNo GYes b. Union: 10. Social Security Number: _____________________(Not mandatory; SSN may be used to identify assets.) 11. a. Spouse's Name:_____________________________________________________________________ b. Spouse's Present or PastEmployer:_____________________________________________________ c. FROM________________ TO __________________ d. Salary: $__________________________ 12. DEPENDENTS: 1)Name a. __________________________________________ b. __________________________________________ c. __________________________________________ d. __________________________________________ e. __________________________________________ f. __________________________________________ g. __________________________________________ h. __________________________________________ 2)Age _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ 3)Relationship ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ SC Financial Statement Affidavit-1 (Rev. 1/98 American LegalNet, Inc. www.FormsWorkFlow.com 13. MONTHLY EXPENSES 1) Expense a. Housing: Rent/Mortgage b. Utilities: Gas/Electric/ Water/Garbage c. Telephone d. Food e. Transportation (gas/bus) f. Car payment g. Insurance h. Child Support/Alimony i. Loans/Credit Card (List): i.______________________ ii.______________________ iii.______________________ iv.______________________ v. ______________________ j. Medical (not covered by insurance) k. Child Care l. IRS Back Taxes 2) Your share of payment $ $ $ $ $ $ $ $ $____________________ $____________________ $___________________ $___________________ $___________________ $ $ $ $ $ $ $ $ $ $ $ $_________________ $_________________ $_________________ $_________________ $_________________ $ $ $ $_________________ $_________________ $_________________ $_________________ $ 14. INCOME INFORMATION a. Number of Permanent Fund Dividend checks received by your family within the past year b. Your total net income (after taxes, but before other deductions) in the past 12 months c. Your spouse's total net income during the past 12 months d. Any money you expect to receive in the next 6 months (e.g. settlements, annuities) e. Are you a seasonal employee? GNo GYes (Specify) $ $ $ 3) Balance owed $ $ $ $ $ $ $ $ $__________________ $__________________ $__________________ $__________________ $__________________ $ $ $ $__________________ $__________________ $__________________ $__________________ $ 4) Amount past due m. Debts (List): i._______________________ $____________________ ii._______________________ $___________________ iii._______________________ $___________________ iv._______________________ $___________________ n. TOTALS $ SC Financial Statement Affidavit-2 (Rev. 1/98 American LegalNet, Inc. www.FormsWorkFlow.com 14. INCOME INFORMATION (CONT.) f. Your total NET monthly income from: 1) Wages: $______________________________ 2) Public Assistance: $_____________________ 3) Unemployment: $_______________________ 4) Other: $_______________________________ Explain:_______________________________ g. Your Spouse's total NET monthly income from: 1) Wages: $______________________________ 2) Public Assistance: $_____________________ 3) Unemployment: $_______________________ 4) Other: $_______________________________ Explain:_______________________________ 15. FAMILY ASSETS (things you own or are buying) 1) Family Assets a. Cash b. Bank Account - checking c. Bank Accounts - savings d. Securities e. Pension Plans/Annuities f. Life Insurance (cash value/dividends) g. Land, Homes, Trailers h. Home Furnishings i. TV, Stereo, VCR, Computer j. Motor Vehicles k. Snow Machines, Boats, ATVs, Motorcyles, Airplanes l. Jewelry, Precious Metals/Stones m. Furs n. Collections (coins, ivory, etc.) o. Tools & Guns p. Sports Equipment q. Fishing Gear r. Limited Entry Permit(s) s. Businesses t. Other (Specify): i._______________ ii.____________________________ u. TOTALS $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $_______________ $_______________ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $________________ $________________ $ 2) Value 3) Amount still owed 4) For court use only v. Specify any of above you need to earn your living and explain why: ______________________________ ________________________________________________________________________________________ SC Financial Statement Affidavit-3 (Rev. 1/98 American LegalNet, Inc. www.FormsWorkFlow.com 16. OATH I declare, under oath, that my Financial Statement is true. DO NOT SIGN THIS AFFIDAVIT UNTIL YOUR SIGNATURE CAN BE WITNESSED. a. _______________________________ b. _______