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Mississippi Affidavit of Indigency Form

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Mississippi Affidavit of Indigency Form
Mississippi Affidavit of Indigency Form
IN THE CIRCUIT COURT OF LINCOLN COUNTY, MISSISSIPPI
STATE OF MISSISSIPPI
VERSUS
CAUSE NO:__________________
______________________________
AFFIDAVIT OF INDIGENCY
Before me, the undersigned officer of said court, this came personally and
Appeared ____________________________, defendant, who by me first duly
sworn, states on oath the following:
1. That he/she is employed/unemployed
2. That he/she earns $___________per week/per month.
3. That he/she owns a _______________________ automobile with/without
encumbrance_____________________________________.
4. That he/she owns other property listed with/without
encumbrance_________________________________________________.
5. That he/she is married/unmarried and has _________ children.
6. That he/she has $_________ in checking account/$___________ in savings
account.
Further, by reason of poverty he/she is unable to employ counsel.
Affiant understands that any false statement made in the affidavit could subject him/her
to prosecution for perjury and/or contempt of court.
______________________________________
AFFIANT
Sworn to and subscribed before me this the _____ day of ________________ , 2013.
______________________________________
DUSTIN R. BAIRFIELD, CIRCUIT CLERK
Mississippi Affidavit of Indigency Form