[DOCKET NO.]

STATE OF MINNESOTA

OFFICE OF ADMINISTRATIVE HEARINGS

 

[PARTY],

                                             Complainant,

vs.

 

[PARTY],

                                             Respondent.

 

AFFIDAVIT FOR PROCEEDING

IN FORMA PAUPERIS

         

1.               I request an order waiving the $50 filing fee in this matter because I am financially unable to pay it.  I believe that I have valid reasons for pursuing this administrative action.

Check any box 2 through 4 that applies to you.

2.                  I am receiving public assistance under one or more of the following programs:

SSI and/or MSA (The Supplemental Security Income and Minnesota Supplemental Assistance Programs);

MFIP (Minnesota Family Investment Program);

Food Stamps;

General Assistance or Work Readiness;

Medical Assistance or General Assistance Medical Care;

Social Security Disability;

Energy Assistance;

And/or Other (specify):

 

3.                  I am represented by an attorney with a civil legal services program or volunteer attorney program, based on indigency.

4.                  My annual family income before taxes is $___________ which is less than 125% of the Federal Poverty Line for my family size of _____members.

If you checked any of boxes 2 through 4 above, skip 5 and sign this document in the presence of a notary public.

 

5.                  I cannot support my family and myself and also pay filing fees and costs.  If you check this box, you must complete the following financial statement.

There are ____ minor child(ren) residing with me.

My net (take home) monthly income is $_____________.

The source of my monthly income is: __________________________.

I pay $________ per month in childcare or support.

I pay $________ per month for rent/mortgage payment.

I own the following property:

     Cash                                                                         $

     Checking, savings and credit union accts           $

Cars, other vehicles - list make, year and equity value (market value minus unpaid loans) for each

_______________________                            $

_______________________                            $

_______________________                            $

Real Estate                                                               $

Other personal property (jewelry, stocks, bonds, etc. list separately)

          ______________________                              $

          ______________________                              $

                I am presently $_____________ in debt.

Other factors which support this affidavit are (explain unusual medical expenses, emergencies or other circumstances to help the Judge understand your situation):

 

Signature (Sign only in front of notary public)

Dated:__________________                 ____________________________________

                                                                                         

Sworn/affirmed before me this

_____day of___________, 2008.

 

__________________________            Name:

Notary Public                                                                     Address:

City/State/Zip:

Telephone:  (       )