STOCKBRIDGE-MUNSEE TRIBAL COURT
Mohican Nation   Stockbridge-Munsee Community  

AFFIDAVIT OF INDIGENCY

  1. This court has jurisdiction over the subject matter and parties in this pursuant to Article of the constitution of the Stockbridge-Munsee Community and Sections of the Stockbridge-Munsee Tribal code.
  2. I am the in the above entitled action.
  3. On information and belief, I am entitled to the redress sought in this action.
  4. Because of poverty, I am unable to pay the costs of this action or to give security to these costs.
Applicants Name Social Security Number Date of Birth

INCOME AND ASSETS:
Applicant's & spouse's sole income (check all that apply): 
W-2  SSI(E)  Relief  Other

Applicant:
 Wage Income   
Name & Phone or Address of Employer:

INCOME:    # Weeks Left    Weekly Gross:
Unemployment Compensation        #Weeks Left     Weekly:        $
Other (self-employed, SSDI; SS, etc.
Unemployed  
Name and Address of Last Employer:
Date Last Employed: 

MARITAL STATUS:  Single/Widowed   Married     Divorced
Spouse: 
If neither applicant nor spouse is employed (and neither receives other income):
How do you support yourself?   Name: Phone:






LIQUID ASSETS OR APPLICANT AND SPOUSE:

  1. Cash                                       
  2. Checking/Savings Account/Trust Funds            Bank: 
  3. Stocks and Bonds:                    Specify: 
  4. Retirement Acct/Cash Value of Life Insurance:  Explain: 
  5. Funds Owed Applicant/Spouse:  Explain:  
  6. Other:  Specify:  

NONE-LIQUID ASSETS OF APPLICANT AND SPOUSE VALUED AT 1/4 EQUITY

Note:  Only include those assets valued at $500.00 or more

  1. House, other real estate:  Value:     Lender?:
  2. Car(s) - Year, make, value: Lender?:
  3. Other: (truck, snowmobile, motorcycle, etc.)  Value: 
  4. Electronics/collections/other:  Value:     

                                                                                                            Total Income and Assets:                           

EXPENSES - COST OF LIVING

        Family # - Check Exemption
        $  992.00
        $1760.00
        $2068.00
        $2468.00
        $2832.

                                                         Total Income, Expenses, Assets, minus family exemptions: