In re:

Petitioner/Plaintiff

and/vs

Respondent/Defendant

I, , am insolvent and unable to pay the charges, costs, and fees otherwise payable by law to the Clerk of Courts or sheriff in this action as evidenced by the following:

1. EMPLOYMENT.

I am currently employed at .

Employer name and address

I earn $ per month average gross pay and $ per month average net pay.

I am currently receiving public assistance in the amount of $ per month.

Case number:

2. ASSETS.

I own the following assets:

Home or other real estate worth $

Cars, boats or trailers worth $

Bank deposits, stocks, or bonds worth $

Other assets worth $

I own no assets.

3. OBLIGATIONS.

I pay the following expenses each month:

Rent $

Utilities $

Court ordered Child Support $

I pay all of the above expenses each month.

I share the above expenses with my spouse or another adult member of my household.

My household includes the following number of children:

I, , further state that I have ( ) / have not ( ) paid or promised to pay a non-lawyer for help in preparing any document in, or for advice concerning, the matter for which I am seeking waiver of costs and fees.

Dated this day of .

Affiant signature

Print name

Address

Telephone

Sworn to or affirmed and ascribed before me this day of by .

Notary Public-State of Florida

Personally Known

Produced ID