Form AOC-495.8 "Financial Statement, Affidavit of Indigency, and Request for Reduced Ignition Interlock Device Costs" - Kentucky

What Is Form AOC-495.8?

This is a legal form that was released by the Kentucky Court of Justice - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2015;
  • The latest edition provided by the Kentucky Court of Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AOC-495.8 by clicking the link below or browse more documents and templates provided by the Kentucky Court of Justice.

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Download Form AOC-495.8 "Financial Statement, Affidavit of Indigency, and Request for Reduced Ignition Interlock Device Costs" - Kentucky

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AOC-495.8
Doc. Code: AOII
Case No. ____________________
Rev. 7-15
Page 1 of 2
l e x
e t
Court
____________________
j u s t i t i a
Commonwealth of Kentucky
County
____________________
Court of Justice
www.courts.ky.gov
FINANCIAL STATEMENT, AFFIDAVIT OF
Division
____________________
INDIGENCY, AND REQUEST FOR REDUCED
KRS 403.761(9)(b); KRS 189A.420
IGNITION INTERLOCK DEVICE COSTS
COMMONWEALTH OF KENTUCKY
PLAINTIFF
VS.
_______________________________________________
DEFENDANT
Address:________________________________________
_______________________________________________
(
)
Telephone: _____________________________
FINANCIAL STATEMENT:
1.
Income:
Employed?
[ ] Yes
[ ] No
If Yes:
[ ] Full-time
[ ] Part-time
[ ] Temporary/Seasonal Length of Employment: ___________
Income from Employment:
[ ] monthly
[ ] biweekly
[ ] hourly $_______________
If No, date last employed: _____________________________
Married?
[ ] Yes
[ ] No
If Yes, Spouse Employed?
[ ] Yes
[ ] No
If Yes, Spouse’s Income from Employment:
[ ] monthly
[ ] biweekly
[ ] hourly $________________
Total Income from ALL other source(s) and amount received per month:
[ ] Welfare: $__________
[ ] Food Stamps:$ ___________
[ ] Social Security/Disability:$____________
[ ] Worker’s Comp: $________
[ ] Unemployment:$____________ [ ] Retirement:$____________
[ ] Child Support/Maintenance: $__________
[ ] Stocks, Trusts, Bonds:$______________
[ ] Child Care Assistance: $___________________
[ ] Other : __________________
Total Income from ALL other source(s): $ _______________________
TOTAL MONTHLY INCOME:
$________________________
2.
Property:
Own Real Estate?
[ ] Yes
[ ] No
If Yes, Value of Real Estate:
$_________________
Amount owed : $_______________
Own Mobile Home?
[ ] Yes
[ ] No
If Yes, Value of Mobile Home:
$_________________
Amount owed : $_______________
Own Personal Property:
Motor Vehicles in Operable Condition (including motor cycles, riding lawn mowers, ATVs, etc.):
Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________
Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________
Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________
Bank Accounts:
[ ] Yes
[ ] No
If Yes, total balance of all accounts: $________________________
Other Asset(s) (i.e., boat, jewelry, cash)
Asset type: _________________ Value: $ _________________ Amount owed: $_______________
Asset type: _________________ Value: $ _________________ Amount owed: $_______________
AOC-495.8
Doc. Code: AOII
Case No. ____________________
Rev. 7-15
Page 1 of 2
l e x
e t
Court
____________________
j u s t i t i a
Commonwealth of Kentucky
County
____________________
Court of Justice
www.courts.ky.gov
FINANCIAL STATEMENT, AFFIDAVIT OF
Division
____________________
INDIGENCY, AND REQUEST FOR REDUCED
KRS 403.761(9)(b); KRS 189A.420
IGNITION INTERLOCK DEVICE COSTS
COMMONWEALTH OF KENTUCKY
PLAINTIFF
VS.
_______________________________________________
DEFENDANT
Address:________________________________________
_______________________________________________
(
)
Telephone: _____________________________
FINANCIAL STATEMENT:
1.
Income:
Employed?
[ ] Yes
[ ] No
If Yes:
[ ] Full-time
[ ] Part-time
[ ] Temporary/Seasonal Length of Employment: ___________
Income from Employment:
[ ] monthly
[ ] biweekly
[ ] hourly $_______________
If No, date last employed: _____________________________
Married?
[ ] Yes
[ ] No
If Yes, Spouse Employed?
[ ] Yes
[ ] No
If Yes, Spouse’s Income from Employment:
[ ] monthly
[ ] biweekly
[ ] hourly $________________
Total Income from ALL other source(s) and amount received per month:
[ ] Welfare: $__________
[ ] Food Stamps:$ ___________
[ ] Social Security/Disability:$____________
[ ] Worker’s Comp: $________
[ ] Unemployment:$____________ [ ] Retirement:$____________
[ ] Child Support/Maintenance: $__________
[ ] Stocks, Trusts, Bonds:$______________
[ ] Child Care Assistance: $___________________
[ ] Other : __________________
Total Income from ALL other source(s): $ _______________________
TOTAL MONTHLY INCOME:
$________________________
2.
Property:
Own Real Estate?
[ ] Yes
[ ] No
If Yes, Value of Real Estate:
$_________________
Amount owed : $_______________
Own Mobile Home?
[ ] Yes
[ ] No
If Yes, Value of Mobile Home:
$_________________
Amount owed : $_______________
Own Personal Property:
Motor Vehicles in Operable Condition (including motor cycles, riding lawn mowers, ATVs, etc.):
Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________
Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________
Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________
Bank Accounts:
[ ] Yes
[ ] No
If Yes, total balance of all accounts: $________________________
Other Asset(s) (i.e., boat, jewelry, cash)
Asset type: _________________ Value: $ _________________ Amount owed: $_______________
Asset type: _________________ Value: $ _________________ Amount owed: $_______________
AOC-495.8
Doc. Code: AOII
Rev. 7-15
Page 2 of 2
3.
Dependents:
[ ] Yes
[ ] No
If Yes, Number of Dependent(s) (including children, elderly, or disabled):
_____________
Relationship of depend
ent(s):
____________
Age(s) of Dependent(s)_______________
4.
Monthly Expenditures:
Mortgage payment/ Rent: [
] Yes
[
] No
If Yes, amount of payment: $
_________________________________
Child support obligation:
[
] Yes
[
] No
If Yes, amount of payment: $
_________________________________
Other out-of-pocket monthly bills (FOR HOUSEHOLD):
[ ] utilities: $
_____________
[ ] water: $_____________
[ ] telephone service (land or cell): $_____________
[ ] internet service: $
_____________
[ ] cable/satellite: $_____________
[ ] car payment: $ _____________
[ ] credit card payments: $
_____________
[ ] car/health/home owners/renters insurance payments: $
_____________
[ ] unreimbursed childcare: $
_____________
[ ] tuition: $_____________
[ ] medical debts: $_____________
[ ] student loan payments: $
_____________
[ ] Other Financial Obligations: $ _____________
Total of other out-of-pocket monthly bills:
$_______________________________
TOTAL MONTHLY EXPENDITURES:
$
_______________________________
Request for Reduced Ignition Interlock Device Costs: I state to the court that I am without sufficient financial means
or assets to pay the full amount of the costs associated with leasing or purchasing, installing, servicing and monitoring
interlock device.
PERJURY WARNING: I understand that knowingly making any false statement in this Financial Statement, Affidavit of
Indigency, and Request for Reduced Ignition Interlock Device Costs may subject me to the penalties for perjury as contained
in KRS Chapter 523, exposing me to a maximum sentence of five (5) years imprisonment. I declare under the penalty
of perjury that I have read or have had read to me the above Financial Statement and Affidavit of Indigency and that the
information contained within is true, complete, and accurate to the best of my knowledge. I also further swear to timely
inform the Court of any significant changes in any of the information in the above Affidavit of Indigency.
_____________
__________________
, 2
______
__________________________________________
Date
Affiant’s Signature
_____
__________________________
, 2
______
__________________________________________
Date
Signature/Title of Officer Administering Oath
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