Forms

STATE OF WISCONSIN MUNICIPAL COURT CITY OF RACINE

Affidavit Of Indigency (Poverty)

Under oath, I state that because of poverty,
I am unable to pay the forfeiture ordered by
the City of Racine Municipal Court.

Affidavit Of Indigency (Poverty)

"*" indicates required fields

Under oath, I state that because of poverty, I am unable to pay the forfeiture ordered by the City of Racine Municipal Court.
I currently receive (check all that apply)
Supplemental security income
Food stamps/food share
Benefits for veterans under §45.40(1m) or 38 USC 501-562 (subsistence aid to needy veterans)
Legal representation from a civil legal services program, a public defender program, or a volunteer attorney program based on indigency.
Relief funded under Wis. Stat. §59.53(21) (county relief programs)
Relief funded under public assistance
Medical assistance
Other means-tested public assistance
Name of Program
My financial situation has not changed since I became eligible for this program/ these programs.
My financial situation has not changed since I became eligible for this program/ these programs.
Income information
I am Employed
Name of employer*
I earn: $*
Every*

Week

Bi-Weekly

Monthly
Monthly income source:
I receive monthly income from the following (include amounts):
Pension
Social Security
Unemployment
Disability
Student loans/grants
Other
$
I have the following cash assets
Savings accounts
Checking accounts
Cash
Checking accounts
$
I have the following other assets
Vehicle
Real Estate
Other assets valued over $200
$
Household Information
My household consists of myself and number of other people
Marital status
I am Married
Spouse's Full Name
Age
Under 18
Relationship to me
Full Name
Age
Under 18
Relationship to me
Full Name
Age
Under 18
Relationship to me
Full Name
Age
Under 18
Relationship to me
Full Name
Age
Under 18
Relationship to me
Full Name
Age
Under 18
The other members of my household have a gross monthly income totaling the amount of: $
The other members of my household collect monthly income from the following sources
Wages
Social Security
Relief under public assistance
Food stamps
Pension
Student loans/grants
Unemployment compensation
SSI
Disability
Relief funded under 59.23(21)
Child support/maintenance
I do not receive income from any other source because
I ask that the court also consider my unique circumstances (such as unusual debt or circumstances)
I herby sign under penalty of perjury
Name*
Date*
MM slash DD slash YYYY

Phone Number*
Address*
City State / Province / Region ZIP / Postal Code

Contact Information

Forms

Affidavit Of Indigency (Poverty)

Affidavit Of Indigency (Poverty)

My financial situation has not changed since I became eligible for this program/ these programs.

Household Information

I herby sign under penalty of perjury