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Decision Information
Rule Set 23 - Supreme Court General Rules - cited by 501 documents
Decision Content
4-222. Application for free process and affidavit of indigency.
[For use with Supreme Court General Rule 23-114 NMRA]
STATE OF NEW MEXICO
COUNTY OF___________________
________________________ COURT
_______________________________, Petitioner,
v. No. ________________
_______________________________, Respondent.
APPLICATION FOR FREE PROCESS AND AFFIDAVIT OF INDIGENCY
I request that the court enter an order permitting me to file this case without prepayment of fees and costs and give upon my oath or affirmation the following statement.
My marital status is: Single ____ Married ____ Divorced ___ Separated ____ Widowed____
I request interpretation services: ___ yes ___ no (If yes, please describe what you need)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
INFORMATION ABOUT MY FINANCES (check all that apply to you 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
___ Medicaid (for myself)
___ General Assistance (GA)
___ Supplemental Security Income (SSI)
___ Public Housing
___ Disability Security Income (DSI)
___ Department of Health Case Management Services (DHMS)
___ 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. I am paid $______ per hour and work _____ hours per week.
My employer’s name, address and phone number 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.
___ I am married, and my spouse is employed. My spouse is paid $______ per hour and works ______ hours per week.
My spouse’s employer’s name, address and phone number is:
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
C. OTHER SOURCES OF INCOME (check all that apply)
___ I have income from another source not mentioned above.
____ Child Support $_________
____ Alimony $_________
____ Investments $_________
____ Community property from my spouse $_________
____ 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 _________________________ $_________
____ Other _________________________ $_________
___ I am married, and my spouse does not have any other sources of income.
___ Another adult contributes to household income in the following amount: $______
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 $__________
Income tax refund $__________
Other assets (describe below):
____________________ $__________
____________________ $__________
IF YOU DO NOT HAVE ACCESS TO YOUR OWN OR YOUR SPOUSE’S INCOME OR ASSETS, EXPLAIN WHY.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
E. MONTHLY EXPENSES
House Payment/Rent $__________
Utilities $__________
Telephone $__________
Groceries (after food stamps) $__________
Car Payment(s) $__________
Gasoline $__________
Insurance $__________
Child Care $__________
Student and Consumer Loans $__________
Court-ordered family support obligations $__________
Other court-ordered payments $__________
Medical expenses $__________
Other____________________ $__________
F. HOUSEHOLD
I live at _______________________________________________________________, and the head of the household is ___________________________________________.
Other than myself, the other members of the 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. If at any time the Court discovers that information in this application for free process 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 under an order of free process that was granted based on the information in this application.
___________________________________
(Signature)
___________________________________
(Print Name)
____ Petitioner ____ Respondent
(Pro Se)
___________________________________
(Street Address)
___________________________________
(City, State, Zip Code)
___________________________________
(Telephone)
State of ____________________________)
) ss
County of __________________________)
Signed and sworn to (or affirmed) before me on __________________________________ (date) by ______________________ (name of applicant).
________________________________
Notary
My commission expires: ____________
IF YOU ARE REPRESENTED BY AN ATTORNEY, YOUR ATTORNEY MUST SIGN THE FOLLOWING CERTIFICATE.
I, ______________________ (name of attorney), hereby certify that I have not received any attorney fee to represent ____________________ (name of applicant). If any attorney fee is paid to me, I understand that I shall pay to the court clerk from such attorney fee any court fees and costs that may be waived by the court.
___________________________________
(Attorney signature)
___________________________________
Address
___________________________________
City, State, Zip Code
___________________________________
Telephone/Fax Number
[Adopted by Supreme Court Order No. 07-8300-043, effective February 25, 2008; as amended by Supreme Court Order No. 08-8300-031, effective November 17, 2008; by Supreme Court Order No. 10-8300-044, effective February 9, 2011.]