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Mississippi Affidavit to Commence or Continue Suite without Prepayment or Payment of Court Costs Form

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Mississippi Affidavit to Commence or Continue Suite without Prepayment or Payment of Court Costs Form
Mississippi Affidavit to Commence or Continue Suite without Prepayment or Payment of Court Costs Form
IN THE CHANCERY COURT OF ____________________ COUNTY, MISSISSIPPI
__________________ JUDICIAL DISTRICT
AFFIDAVIT TO COMMENCE OR CONTINUE SUITE WITHOUT
PREPAYMENT OR PAYMENT OF COURT COSTS
STATE OF MISSISSIPPI
COUNTY OF ____________: : : :
I, __________________________________, being first duly sworn, depose and state that
based upon my personal knowledge and oath, the following responses are true and correct:
1. State your full name: ____________________________________________________
Present address: ________________________________________________________
________________________________________________________
________________________________________________________
Social Security Number: XXX-XX-__________________
Telephone number: __________________________
Full name of Spouse: __________________________
Number of dependents
for whom you provide support: ________________
2. Did you file a Federal Income Tax Return for either of the preceding two years Yes No
a. If yes, please attach a copy of your tax return(s) to this affidavit.
3. Did you receive an income tax refund or earned income credit for either of the last two
tax years Yes No
a. If so, in what amount last year _________________________________
b. In what amount for the preceding year ___________________________
4. Are you presently employed Yes No
a. If yes, state the amount of your salary or wages per month and give the name and
address of your employer.
i. Monthly salary or wages. _______________________________________
ii. Present employer: _______________________________________
_______________________________________
_______________________________________
5. Did you receive any monetary income from any source such as SSI, disability, DHS
transfer payments, pension wages, child support, regular gifts, etc Yes No
Mississippi Affidavit to Commence or Continue Suite without Prepayment or Payment of Court Costs Form
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