Financial Affidavit

FINANCIAL AFFIDAVIT
Personal Information
Name:*

First NameLast Name
Case Number(s):
List all cases which you have delinquent fines.
Mailing Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone:*
Format: (000) 000-0000.
Email Address:
Social Security Number:
Date of Birth:*

MonthDayYear
Date
Driver's License Number:
Driver's License State:

Street Address

Street Address Line 2

CityState

Zip Code
Income Information
YesNo
Employer Name:
Employer Phone:
Format: (000) 000-0000.
Employer Address:
Monthly Income Amount (Gross):
Amount before taxes are deducted.
WeeklyEvery two weeksMonthly
Household Size:
Household Income:
YesNo
MedicaidSocial SecurityOther
Miscellaneous Information
Number of Dependents:
YesNo
How much child support do you pay per month?
YesNo
Name of bank(s):
YesNo
Pending criminal case numbers:
YesNo
YesNo
YesNo
Verification
I certify under penalty of perjury that the information on this financial affidavit is true and correct.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

FINANCIAL AFFIDAVIT