Case Information

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14. $15-00086\mathrm{C}\mathrm{V}$

Affidavit of Indigency

(Request to Not Pay Court Fees)

Use this form to ask the court not to charge you for court fees. This form is also called an "Affidavit of Inability to Pay Court Costs" or a "Pauper's Oath." You can only use this form if: (1) you get public benefits because you are poor or (2) you can't pay court fees. The information you give on this form must be current, complete, true and correct.

You must either 1) sign this form in front of a notary public or 2) sign this form and sign and attach a completed "Unsworn Declaration" form. By signing in front of a notary, you swear under oath that the information provided is true and correct. By signing and attaching an "Unsworn Declaration" form, you declare under penalty of perjury that the information provided is true and correct.

You can be prosecuted if you lie on this form. The court may or may not approve this request to not pay court fees. The court may order you to answer questions about your finances at a hearing. At that hearing you will have to present evidence to the judge of your income and expenses to prove that you have no ability to pay court fees. (1) The person who signed this affidavit appeared, in person, before me, the undersigned notary, and stated under oath: "My name is "My mailing address is "My email address is

"My phone number is $\left(\begin{array}{cc}23\hfill & amp;2\hfill \end{array}\right)991.3295$ The same is $\frac{\text{Tern}}{\text{"My}}$ is $\frac{2005}{2005}$ "My phone number is $\left(\begin{array}{cc}23\hfill & amp;2\hfill \end{array}\right)991.3295$ The court may or may not approve this request to not pay court fees. The court may order you to answer questions about your finances at a hearing. At that hearing you will have to present evidence to the judge of your income and expenses to prove that you have no ability to pay court fees. (3) "My income sources are stated below. (Check all that apply) Unemployed since: (date) Wages: I work as a $◻$ Unemployed since: (date) Wages: I work as a

$◻$ Child/spousal support $◻$ My spouse's income or income from another member of my household (if available) $◻$ Tips, bonuses $◻$ Military Housing $◻$ Worker's Comp $◻$ Disability $◻$ Unemployment $◻$ Social Security $◻$ Retirement/Pension $◻$ Dividends, interest, royalties $◻2^{\text{nd}}$ job or other income: $◻$ (describe) (4) "My Income amounts are stated below. (a) My monthly net income after taxes are taken out is: (b) The amount I receive each month in public benefits is: (c) The amount of income from other people in my household is:* (d) The amount I receive each month from other sources is: (e) My TOTAL monthly income is

Add all sources of income above $\to$

$$

*2 (3) About my dependents: "The people who depend on me financially are listed below: Name Age Relationship to Me

"The value is the amount the item would sell for less the amount you still owe on it (if anything). (6) "My debts include: List debt and amount owed. 47.2000 .100

To list any other facts you want the court to know, such as unusual medical expenses, family emergencies, etc., attach another page to this form and label it "Exhibit: Additional Supporting Facts." Check here if you attach another page. $◻$ (9) "I am unable to pay court costs. I verify that the statements made in this affidavit are true and correct." (10) Your Signature. You must either: 1) sign this form in front of a notary public or 2) sign this form and sign and attach a completed "Unsworn Declaration" form.

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Your New Benefit Amount

BENEFICIARY'S NAME: TOM J JONES

Your Social Security benefits will increase by 1.7 percent in 2015 because of a rise in the cost of living. You can use this letter when you need proof of your benefit amount to receive food, rent, or energy assistance; bank loans; or for other business. Keep this letter with your important financial records.

How Much Will I Get And When?

• Your monthly amount (before deductions) is
• The amount we deduct for Medicare medical insurance is (If you did not have Medicare as of Nov. 20, 2014, or if someone else pays your premium, we show $\$0.00$ .)
• The amount we deduct for your Medicare prescription drug plan is (If you did not elect withholding as of Nov. 1, 2014, we show $\$0.00$ .)
• The amount we deduct for voluntary Federal tax withholding is (If you did not elect voluntary tax withholding as of Nov. 20, 2014, we show $\$0.00$ .)
• After we take any other deductions, you will receive on or about Jan. 2, 2015.

If you disagree with any of these amounts, you must write to us within 60 days from the date you receive this letter. We would be happy to review the amounts.

You may receive your benefits through direct deposit, a Direct Express ${}^{\circledR }$ card, or an Electronic Transfer Account. If you still receive a paper check and want to switch to an electronic payment, please visit the Department of the Treasury's Go Direct website at www.godirect.org.

What If I Have Questions?

Please visit our website at www.socialsecurity.gov for more information and a variety of online services. You also can call 1-800-772-1213 and speak to a representative from 7 a.m. until 7 p.m., Monday through Friday. Recorded information and services are available 24 hours a day. Our lines are busiest early in the week, early in the month, as well as during the week between Christmas and New Year's Day; it is best to call at other times. If you are deaf or hard of hearing, call our TTY number, 1-800-325-0778. If you are outside the United States, you can contact any U.S. embassy or consulate office. Please have your Social Security claim number available when you call or visit and include it on any letter you send to Social Security. If you are inside the United States and need assistance of any kind, you can visit your local office.