"Poverty Affidavit Form" - Kansas

Poverty Affidavit Form is a legal document that was released by the Kansas Judicial Branch - a government authority operating within Kansas.

Form Details:

  • Released on July 1, 2013;
  • The latest edition currently provided by the Kansas Judicial Branch;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Kansas Judicial Branch.

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Download "Poverty Affidavit Form" - Kansas

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07/01/13
IN THE ________JUDICIAL DISTRICT
DISTRICT COURT OF __________ COUNTY, KANSAS
_____________________,
)
)
Plaintiff,
)
)
vs.
)
Case No. ___________
)
____________________,
)
)
Defendant.
)
POVERTY AFFIDAVIT
Note: Do not use this form if you are currently an inmate in the custody of the secretary of
corrections. You should use the Poverty Affidavit – Inmate form or, if you are filing a motion
under K.S.A. 60-1507, you should use the forms relating to Supreme Court Rule 183.
I,
, am unable to pay a docket fee in this matter
by reason of poverty. Pursuant to K.S.A. 60-2001(b)(2), the following information is provided
in support.
Employment: I am ___ employed; ___ not employed.
My employer is:
_______________________________
My employer’s address is:
_______________________________
_______________________________
_______________________________
Income: I receive income from the following sources (list amount per week):
Employment income (after withholdings):
$____________
Rental income:
$____________
Interest and / or dividends:
$____________
Spousal support and / or child support:
$____________
Retirement, pension, social security:
$____________
Disability, workers compensation:
$____________
Unemployment benefits:
$____________
1
07/01/13
IN THE ________JUDICIAL DISTRICT
DISTRICT COURT OF __________ COUNTY, KANSAS
_____________________,
)
)
Plaintiff,
)
)
vs.
)
Case No. ___________
)
____________________,
)
)
Defendant.
)
POVERTY AFFIDAVIT
Note: Do not use this form if you are currently an inmate in the custody of the secretary of
corrections. You should use the Poverty Affidavit – Inmate form or, if you are filing a motion
under K.S.A. 60-1507, you should use the forms relating to Supreme Court Rule 183.
I,
, am unable to pay a docket fee in this matter
by reason of poverty. Pursuant to K.S.A. 60-2001(b)(2), the following information is provided
in support.
Employment: I am ___ employed; ___ not employed.
My employer is:
_______________________________
My employer’s address is:
_______________________________
_______________________________
_______________________________
Income: I receive income from the following sources (list amount per week):
Employment income (after withholdings):
$____________
Rental income:
$____________
Interest and / or dividends:
$____________
Spousal support and / or child support:
$____________
Retirement, pension, social security:
$____________
Disability, workers compensation:
$____________
Unemployment benefits:
$____________
1
Other Income (Describe) ____________________________
$____________
TOTAL weekly income from all sources:
$____________
Assets on Hand: I presently have the following assets (list value):
Cash (including bank accounts and electronic accounts):
$____________
Automobile, truck or other vehicle:
$____________
Real property (home, building or land):
$____________
Other assets (jewelry, watches, etc.)
$____________
Other Assets: Are you a beneficiary of any current estate, trust, annuity, or life insurance
policy? If so, please provide the details.
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
Other Reasons: Explain any other facts or reasons why you cannot afford to pay a docket fee in
your case.
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
I,
, declare under penalty of perjury that the
information set forth in this affidavit is true and correct and that, by reason of my poverty, I am
unable to pay the docket fee.
Executed on
, 20
.
________________________________
Signature of Plaintiff
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