IN THE TENTH JUDICIAL CIRCUIT COURT IN AND FOR
POLK COUNTY, FLORIDA
AFFIDAVIT OF INSOLVENCY
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:
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.
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.
I pay the following expenses each month:
Court ordered Child Support $
Transportation (if you dont own a car) $
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 .
Sworn to or affirmed and ascribed before me this day of by .
Notary Public-State of Florida