Mont. Admin. r. 23.2.301
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:
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 ____________________________________________
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 $ ___________
Spouse's motor vehicles _________________________________
Is/are vehicle(s) paid for? Yes ________ No ___________
If not, how much do you owe? $ ________________________________
Year, make and model _________________________________
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? ______________________
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: _________________________________
Do you or your spouse have any outstanding debts or obligations: (specify and list amount): ____________________________________________
_______________________________________________________
_______________________________________________________
I further declare that I am the person named above, that I have read the foregoing questions and information and know the same to be true of my own knowledge, AND THAT IF ANY PART OF THE ABOVE IS MADE FALSELY I AM SUBJECT TO PROSECUTION FOR PERJURY.
_________________________________
Signature of Requestor
SUBSCRIBED AND SWORN TO before me this ______________ day of ______________________, 19___.
_________________________________
Notary Public for the State of Montana
Residing at ________________, Montana
My Commission expires ______________________
ORDER
Indigence status is hereby denied/granted.
DATED: _____________________________
_________________________________
Judge/Administrative Officer
Mont. Admin. r. 23.2.301
AUTH: 2-4-307, 18-2-409, 18-2-431, MCA; IMP: 18-2-401, 18-2-402, 18-2-403, 18-2-406, 18-2-411, 18-2-412, 18-2-413, 18-2-414, 18-2-415, 18-2-422, 18-2-431, MCA