New Mexico Forms Library

10-510. Affidavit of indigency; abuse or neglect.

[For use with Section 32A-4-10 NMSA 1978]

 

STATE OF NEW MEXICO

COUNTY OF _______________

__________________ JUDICIAL DISTRICT

IN THE CHILDREN’S COURT

 

STATE OF NEW MEXICO ex rel.

CHILDREN, YOUTH AND FAMILIES DEPARTMENT

 

                                                                                                            No. __________

 

In the Matter of

_______________________________, (a) Child(ren), and Concerning

_______________________________, Respondent(s).

 

 

AFFIDAVIT OF INDIGENCY

 

            I give upon my oath or affirmation the following statement:

 

My marital status is single ___ married ___ divorced ___ separated ___ widowed ___.

 

INFORMATION ABOUT MY FINANCES (Check all that apply and fill in the blanks.)

 

A.        PUBLIC ASSISTANCE

 

            ___     I do not receive public assistance.  (If you check this blank, go directly to Section B, EMPLOYMENT/UNEMPLOYMENT).

 

            ___     I currently receive the following public assistance in ______________ County

                        (please check all applicable public assistance programs):

                        Temporary Assistance for Needy Families (TANF) ___;

                        Food Stamps ___;

                        General Assistance (GA) ___;

                        Public Housing ___;

                        Department of Health Case Management Services (DHMS) ___;

                        Medicaid ___;

                        Supplemental Security Income (SSI) ___;

                        Social Security Disability Income (SSDI) ___;

                        Veterans Disability Benefits (VA) ___;

                        Other (please describe) _______________________________________.

 

 

B.        EMPLOYMENT/UNEMPLOYMENT

 

            ___     I am currently unemployed and have been unemployed for ___ months in the past year.  I am unemployed because ____________________________________.

                        ___     I receive unemployment benefits in the amount of $_____ per month.

                        ___     I have no income because I am unemployed.

 

            ___     I am employed. My employer’s name, address, and phone number is:

                        ____________________________________________________________

                        ____________________________________________________________

                        ____________________________________________________________.

 

            ___     I am self-employed. ________________________ (Describe nature of the business.)

 

            ___     I am paid

                        ___ daily

                        ___ weekly

                        ___ every other week

                        ___ twice a month

                        ___ once a month.

When I am paid, my net take-home pay minus deductions required by law, like state and federal tax withholding and FICA, is $________.

 

            ___     I am married, and my spouse is unemployed and has been unemployed for ___ months in the past year because

                        ____________________________________________________________

                        ____________________________________________________________.

                        ___     My spouse receives unemployment benefits in the amount of $_____ per month.

                        ___     My spouse does not have an income because he or she is unemployed.

 

            ___     I am married, and my spouse is employed. My spouse’s employer’s name, address, and phone number is:

                        ____________________________________________________________

                        ____________________________________________________________

                        ____________________________________________________________.

 

            ___     I am married, and my spouse is self-employed. _____________________

                        (Describe nature of the business.)

 

            ___     My spouse is paid

                        ___ daily

                        ___ weekly

                        ___ every other week

                        ___ twice a month

                        ___ once a month.

When my spouse is paid his or her net take-home pay minus deductions required by law, like state and federal tax withholding and FICA, is $ _________.

 

C.        OTHER SOURCES OF INCOME

 

            ___     I have income from another source not mentioned above.

                        ___ Child support $_____

                        ___ Alimony $_____

                        ___ Investments $ _____

                        ___ Other _________________________ $ _____

 

            ___     I do not have any other sources of income.

 

            ___     I am married, and my spouse has income from another source not mentioned above.

                        ___ Child support $_____

                        ___ Alimony $_____

                        ___ Investments $_____

                        ___ Other __________________________ $ _____

 

            ___     I am married, and my spouse does not have any other sources of income.

 

D.        OTHER ASSETS (Please list other assets owned by you or your spouse that can be turned into cash.  Do not include money you have in retirement accounts.)

 

Cash on hand                                               $ _________

Bank accounts                                              $ _________

Stocks/bonds                                    $ _________

Income tax refund                                        $ _________

Real estate (other than primary residence)         value: $ ________   debt: $ _________

Vehicles (other than primary vehicle)       value: $ ________   debt: $ _________

Other assets (describe below):

___________________                              $ _________

___________________                              $ _________

 

IF YOU DO NOT HAVE ACCESS TO YOUR OWN OR YOUR SPOUSE’S INCOME OR ASSETS, EXPLAIN WHY.

______________________________________________________________________

______________________________________________________________________

_____________________________________________________________________.

 

E.        EXCEPTIONAL EXPENSES:

 

Medical expenses (not covered by insurance)    $ _________

Medical insurance payments                                  $ _________

Court ordered support payments/alimony            $ _________

Child care payments (e.g., day care)                    $ _________

Any funds garnished from paycheck                    $ _________

Other (describe)                                                       $ _________

TOTAL EXCEPTIONAL EXPENSES                  $ _________

 

F.         HOUSEHOLD 

 

I live at _______________________________________________________________.

 

Other than myself, the other members of my household are:

 

Name                                                 Age                 Employment              I Support

_________________________    _______        _____________       (             )

_________________________    _______        _____________       (             )

_________________________    _______        _____________       (             )

_________________________    _______        _____________       (             )

_________________________    _______        _____________       (             )

_________________________    _______        _____________       (             )

_________________________    _______        _____________       (             )

 

This statement is made under oath.  I hereby state that the above information regarding my financial condition is correct to the best of my knowledge.  I hereby authorize the court to obtain information from financial institutions, employers, relatives, the federal internal revenue service, and other state agencies.  I understand that the court may require documentation for any information listed above.  If at any time the court discovers that information in this affidavit was false, misleading, inaccurate, or incomplete at the time the application was submitted, the court may require me to pay for any costs or fees that were waived based on the information in this application.

 

                                                                        ________________________________

                                                                        (Signature)

                                                                        ________________________________

                                                                        (Print name)

                                                                        ________________________________

                                                                        (Street address)

                                                                        ________________________________

                                                                        (City, state, and zip code)

                                                                        ________________________________

                                                                        (Telephone)

 

State of ________________________   )

                                                                        )           ss.

County of ______________________     )

 

 

Signed and sworn or affirmed to before me on ________________________________ (date) by ______________________________ (name of applicant).

 

                                                                                    ________________________________

                                                                                    Notary Public

                                                                                    My commission expires: ____________

 

GUIDELINES FOR DETERMINING ELIGIBILITY

 

            Court administration or the respondent’s attorney shall assist the respondent in completing this form. This form should be served with the petition on the respondent.

            An applicant is presumed indigent if the applicant is the current recipient of aid from a state or federally administered public assistance program, such as Temporary Assistance for Needy Families (TANF), General Assistance (GA), Supplemental Security Income (SSI), Social Security Disability Income (SSDI), VA Disability Benefits, Department of Health Case Management Service (DHMS), Food Stamps, Medicaid, or public assisted housing.

            An applicant who is not presumptively indigent can, nevertheless, establish indigency by showing in the application that the applicant’s available funds (annual income + assets - expenses) do not exceed one hundred fifty percent (150%) of the federal poverty guidelines established by the United States Department of Health and Human Services.  (See www.aspe.hhs.gov/poverty/ for current federal poverty guidelines.)

            A presumption of indigency under this rule does not require the court to find an applicant indigent and therefore entitled to a court appointed attorney if it appears from the application that the applicant is otherwise able to pay.

            Even if an applicant cannot establish indigency, the court may still appoint an attorney if, in the court’s discretion, appointment of counsel is required in the interests of justice.

            If at any time the court discovers that information in an application for indigency was false, misleading, inaccurate, or incomplete at the time the application was submitted, and that the determination of indigency was improvidently made, the court may require the applicant to pay the court-appointed attorney fees.

 

[Adopted by Supreme Court Order No. 10-8300-022, effective August 30, 2010; 10-456A recompiled and amended as 10-510 by Supreme Court Order No. 14-8300-009, effective for all cases filed or pending on or after December 31, 2014.]