Free Certified Statement In Support Of Motion To Leave To Proceed As An Indigent - New Jersey

CERTIFIED STATEMENT IN SUPPORT OF MOTION FOR LEAVE TO PROCEED AS AN INDIGENT PLEASE PRINT OR TYPE ALL INFORMATION
Clear form

(1)

Name Address Date of Birth EMPLOYMENT Number of Dependents

Phone #

(2)

Employed By Position ASSETS (Attach additional sheets if necessary) Monthly Salary $

(3)

Other Income (Source and Monthly Amount) Checking/Savings Accounts (Name of Banking Institution and Present Balance)

(4)

(5)

Real Estate (Address, Present Value and Equity)

(6) (7) (8)

Personal Property (Item and Present Value) Auto/Truck/Motorcycle (Year, Make and Present Equity) Other Assets (Type and Present Value) LIABILITIES (Attach additional sheets if necessary)

(9)

Mortgage/Rent/Halfway House Payment Per Month $

Mortgage Balance $

(10) Outstanding Loans (Nature and Present Balance) (11) Credit Cards (Name and Present Balance) (12) Other Liabilities (Type and Present Amount) (13) SET FORTH ANY OTHER RELEVANT INFORMATION CONCERNING YOUR FINANCIAL CIRCUMSTANCES:

CERTIFICATION IN LIEU OF OATH (COURT RULE 1:4-4(b)) I CERTIFY THAT THE FOREGOING STATEMENTS MADE BY ME ARE TRUE. I AM AWARE THAT IF ANY OF THE FOREGOING STATEMENTS MADE BY ME ARE WILLFULLY FALSE, I AM SUBJECT TO PUNISHMENT.

(14) Signature
ADMIN-18 3/96

Date: