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VIRGINIA:
IN THE COURT OF APPEALS
_____________________________________,
Appellant(s),
against
Record No.__________________
_____________________________________,
Appellee(s).
AFFIDAVIT OF INDIGENCE
NAME:
ADDRESS:
OCCUPATION:
NUMBER OF DEPENDENTS:
MONTHLY INCOME:
MONTHLY INCOME OF SPOUSE:
MONTHLY INCOME OF EMPLOYED DEPENDENTS:
AMOUNT ON DEPOSIT IN BANKS:
VALUE OF EQUITY IN REAL ESTATE:
INCOME PRODUCED BY REAL ESTATE:
OTHER INCOME:
VALUE OF PERSONAL PROPERTY:
MAKE, MODEL AND YEAR OF CARS OWNED:
VALUE OF INTEREST IN OTHER PROPERTY:
APPROXIMATE INDEBTEDNESS:
AMOUNT
LENDER
I hereby certify that the foregoing
information is accurate to the best of my knowledge.
________________________________
Subscribed and sworn to before me
this____day of_______________________, 19____.
_________________________________
Notary Public
My commission expires______________