Free COA Financial Statement - Alaska

IN THE COURT OF APPEALS OF THE STATE OF ALASKA
FINANCIAL STATEMENT AFFIDAVIT
For use with a motion to waive filing fee, when the basis for the motion is inability to pay, a motion to appeal at public expense, or an application for an exemption from filing fee under AS 9.19.010.
1. Appellant's (or Petitioner's) Name: 2. Appellant's Telephone: 3. Case No.

(for court system use)

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4. Appellant's Residence Address: ___________________________________________________________ _____________________________________________________________________________________ 5. Appellant's Mailing Address: _____________________________________________________________ _____________________________________________________________________________________ 6. a. GMarried GSingle GDivorced GSeparated GWidowed 7. a. Are your working now? GYes GNo b. How long?

b. If not, date last worked:

8. LIST ALL EMPLOYERS FOR THE LAST 12 MONTHS a. 1) Present or Former Employer:_____________________________________________________________ 2) Address & Telephone:__________________________________________________________________ 3) Job Title:_______________________________________ 4) Salary: $__________________per_______ 5) FROM__________________ TO ___________________ 5) No. Hours Per Week__________________
(Month and Year) (Month and Year)

b. 1) Present or Past Employer:_______________________________________________________________ 2) Address & Telephone:__________________________________________________________________ 3) Job Title:_______________________________________ 4) Salary: $__________________per_______ 5) FROM__________________ TO ___________________ 5) No. Hours Per Week__________________
(Month and Year) (Month and Year)

9. a. Do you belong to a Labor Union?

GNo GYes b. Union:

10. Social Security Number: _____________________(Not mandatory; SSN may be used to identify assets.) 11. a. Spouse's Name:_____________________________________________________________________ b. Spouse's Present or PastEmployer:_____________________________________________________ c. FROM________________ TO __________________ d. Salary: $__________________________ 12. DEPENDENTS: 1)Name a. __________________________________________ b. __________________________________________ c. __________________________________________ d. __________________________________________ e. __________________________________________ f. __________________________________________ g. __________________________________________ h. __________________________________________ 2)Age _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ 3)Relationship ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________

COA Financial Statement Affidavit-1 (Rev. 1/98)

13. MONTHLY EXPENSES 1) Expense a. Housing: Rent/Mortgage b. Utilities: Gas/Electric/ Water/Garbage c. Telephone d. Food e. Transportation (gas/bus) f. Car payment g. Insurance h. Child Support/Alimony i. Loans/Credit Card (List): i.______________________ ii.______________________ iii.______________________ iv.______________________ v. ______________________ j. Medical (not covered by insurance) k. Child Care l. IRS Back Taxes 2) Your share of payment $ $ $ $ $ $ $ $ $____________________ $____________________ $___________________ $___________________ $___________________ $ $ $ $ $ $ $ $ $ $ $ $_________________ $_________________ $_________________ $_________________ $_________________ $ $ $ $_________________ $_________________ $_________________ $_________________ $ 14. INCOME INFORMATION a. Number of Permanent Fund Dividend checks received by your family within the past year b. Your total net income (after taxes, but before other deductions) in the past 12 months c. Your spouse's total net income during the past 12 months d. Any money you expect to receive in the next 6 months (e.g. settlements, annuities) e. Are you a seasonal employee? GNo GYes (Specify) $ $ $ 3) Balance owed $ $ $ $ $ $ $ $ $__________________ $__________________ $__________________ $__________________ $__________________ $ $ $ $__________________ $__________________ $__________________ $__________________ $ 4) Amount past due

m. Debts (List): i._______________________ $____________________ ii._______________________ $___________________ iii._______________________ $___________________ iv._______________________ $___________________ n. TOTALS $

COA Financial Statement Affidavit-2 (Rev. 1/98)

14. INCOME INFORMATION (CONT.) f. Your total NET monthly income from: 1) Wages: $______________________________ 2) Public Assistance: $_____________________ 3) Unemployment: $_______________________ 4) Other: $_______________________________ Explain:_______________________________ g. Your Spouse's total NET monthly income from: 1) Wages: $______________________________ 2) Public Assistance: $_____________________ 3) Unemployment: $_______________________ 4) Other: $_______________________________ Explain:_______________________________

15. FAMILY ASSETS (things you own or are buying) 1) Family Assets a. Cash b. Bank Account - checking c. Bank Accounts - savings d. Securities e. Pension Plans/Annuities f. Life Insurance (cash value/dividends) g. Land, Homes, Trailers h. Home Furnishings i. TV, Stereo, VCR, Computer j. Motor Vehicles k. Snow Machines, Boats, ATVs, Motorcyles, Airplanes l. Jewelry, Precious Metals/Stones m. Furs n. Collections (coins, ivory, etc.) o. Tools & Guns p. Sports Equipment q. Fishing Gear r. Limited Entry Permit(s) s. Businesses t. Other (Specify): i._______________ ii.____________________________ u. TOTALS $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $_______________ $_______________ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $________________ $________________ $ 2) Value 3) Amount still owed 4) For court use only

v. Specify any of above you need to earn your living and explain why:______________________________ _______________________________________________________________________________________

COA Financial Statement Affidavit-3 (Rev. 1/98)

16. OATH I declare, under oath, that my Financial Statement is true. DO NOT SIGN THIS AFFIDAVIT UNTIL YOUR SIGNATURE CAN BE WITNESSED. a. _______________________________ b. ___________________________________________________ Date Signature of Appellant/Parent (of appellant under 18) Subscribed and worn to or affirmed before me on __________________________________, 19 _______ in ________________________________, Alaska. c. ___________________________________________________ Notary Public / Deputy Clerk of Court My commission expires: _________________________________ FOR COURT USE ONLY - DO NOT COMPLETE 17. FINANCIAL SUMMARY a. Total family income for the past 12 months b. Total assets (equity) Cash c. Total debts d. Total family income each month e. Total family expenses each month Amount behind f. Total discretionary income each month $_________________ $___________________ $_________________ $_________________ $_________________ $_________________ $___________________ $___________________

(SEAL)

h. I recommend that this request be GDenied. GApproved. i. Reasons: _____________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ j. _______________________________ Date k. __________________________________________________ Signature of Deputy Clerk

COA Financial Statement Affidavit-4 (Rev. 1/98)