Administrative Rules of Montana › Department 23 - JUSTICE › Chapter 23.2 - PROCEDURAL RULES › Subchapter 23.2.3 - Affidavit of Indigence › Rule 23.2.301 - AFFIDAVIT OF INDIGENCE AFFIDAVIT OF INDIGENCE AND ORDER

Current through Register Vol. 13, July 5, 2024
ANSWER ALL QUESTIONS. USE N/A IF NOT
				  APPLICABLE
STATE OF MONTANA )
:ss.
County of _______________________ )
I, _______________________ , being first duly sworn, depose
				  and say: That I have a good cause of action or defense but am unable to pay the
				  costs or get security to secure the cause of action or defense. I request the
				  court or administrative tribunal to waive the costs and approve indigence
				  status. I declare the following:
I.
PERSONAL INFORMATION
Name _______________________________________
Address _______________________________________
Telephone _______________ Birthdate ________ Age ___ SSN
				  ____________
Employed Yes ___ No ____ Self-Employed Yes _____ No
				  ____
Employer's name & address
				  _____________________________
____________________________________________________
Month last employed ________________ Job
				  ________________
Single _____ Married ______ Divorced ____ Separated
				  ___________
Dependents? Spouse _________ Number of children
				  ___________
Spouse's name ________________________________________
Spouse's birthdate ____________ Age _______ Spouse's SSN
				  ___________
Spouse's employer & address
				  _______________________________
_______________________________________________________
Are you sharing expenses with anyone? Yes ___________ No
				  ___________
Explain ____________________________________________
Are you sharing income with anyone? Yes ________ No
				  ___________
Explain ____________________________________________
II.
INCOME
Income available:
My wages or salary $ ______________ AFDC $ ___________
Other wages/salary $ ______________ Unemployment $
				  ___________
Workers' Comp $ ___________________ SSI $ ___________
Food Stamps $ ___________________ Medicaid $
				  ___________
Pension $ ___________________ Retirement $ ___________
Child support $ ___________________ Other Income $
				  ___________
Total Household Income:
Last month $ _____________ Previous 12 months $
				  ___________
III.
ASSETS
A. Motor vehicles? Yes
				___________ No _____________ How many? ___________
Spouse's motor vehicles
				  _________________________________
Is/are vehicle(s) paid for? Yes ________ No
				  ___________
If not, how much do you owe? $
				  ________________________________
Year, make and model
				  _________________________________
B. Do you or your spouse own any land or
				other real estate or are you or your spouse buying any? Yes __________ No
				___________
What is the approximate value? ______________________
How much did you pay for it? $________________ When?
				  ___________
Is it paid for? Yes ________ No _________
If not, how much do you or your spouse owe?
				  ______________________
C.
				Checking accounts? Yes _________ No ___________ $ ___________
Savings accounts? Yes _________ No ___________ $
				  ___________
Bank ____________________________________________
Stocks or bonds? Yes _________ No ___________ $
				  ___________
Wages due but not yet received $
				  ______________________
Money owed to me or my spouse $
				  ______________________
Guns, boats, sporting equipment, trailer, camper, or tools $
				  _________________________________
Stereo or TV $ _________________________________
Furniture & appliances $
				  _________________________________
Other personal property $
				  _________________________________
Specify: _________________________________