Affidavit of Financial Inability to Pay Financial Responsibility

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I swear and affirm that I am the party in the above-entitled action. I want a payment agreement to satisfy the judgment of the court. I am financially unable to pay the amount due without causing substantial hardship to myself or to my family. The following information is true and is given and intended to be relied upon by the court to determine my eligibility for a payment agreement to pay fines and costs.

WARNING AS TO PERJURY: It is a felony to make or sign a statement under oath or affirmation that the statement is true, when in fact the person making the statement knows or believes that it is not true. The punishment for this felony is imprisonment or fine. Thoroughly and legibly complete this affidavit and financial statement. This information will be used in being considered for time to pay by order of the court.

PLEASE FILL IN ALL SPACES BELOW AND SIGN YOUR NAME UNDER OATH. IF A QUESTION DOES NOT APPLY TO YOU, PLEASE LEAVE THE QUESTION BLANK 

1. General Information
Name
Are you a student?
Marital Status
Spouse's Information
Spouse's Name
Are you claimed as a dependent by a Parent or Guardian?
2. Household Income
Are you currently employed?
$
Pay Schedule
If Unemployed
Are you looking for a job?
Do you receive any support from any of the following agencies?

Check any that apply.

Have you been designated as totally (100%) disabled, excluding temporary disability, by any of the following agencies?

Check any that apply.

Is any other member of your household employed?
$
3. Transportation
Make Model Year Value
$
$
Make Model Year Value
$
$
$
4. Assets
$
$
$
$
$
Rent or Own?
$
$
Are you party to a suit (probate, workers’ compensation, personal injury) where judgment may be expected?
5. Income, Expenses and Debts
Monthly Income Received
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$0
Monthly Expenses Paid
$
Utilities (your portion)
$
$
$
$
$
$
$
$0
$
$
$
$
$
$
$
$
$
$
$
$0
$0
6. Other Information
Do you have any friends or relatives who are able to assist you?
Has a friend or relative given previous financial assistance in this case, but is no longer able or willing to do so?
Have you transferred or sold any assets since charges were filed in this case?
Have you retained counsel in this case or in any other pending criminal case?
Agreement

I hereby swear or affirm under penalty of perjury that all my answers are true and correct. I understand that providing false or misleading information may result in further action against me. I grant the Court full permission to make any necessary inquiries or investigations to verify the information I have provided and to obtain any further information. I understand that I must inform the Court of any change in my financial situation that may change the information I have provided.

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