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Financial Affidavit
All patrons wanting an appointment must complete this form. YOU MUST PROVIDE PROOF OF INCOME AT YOUR APPOINTMENT (two pay stubs, benefits letter, etc.)
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Financial Affidavit
Today's Date
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MM
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DD
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YYYY
How did you find out about Middle Georgia Justice?
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Courthouse
Friend
Online
Previous Patron
Tax Assessor's Office
Attorney's Office
GA Legal Services
Other:
Full Name
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Your answer
Phone Number
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Your answer
Email Address
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Your answer
Mailing Address
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Your answer
Date of Birth
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MM
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DD
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YYYY
What is the highest level of schooling you completed?
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Your answer
Are you currently employed?
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Yes
No
Who is your current employer?
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Your answer
If unemployed, for how long?
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Your answer
Gross Income (before taxes). Please specify if this is weekly, biweekly, monthly, or yearly.
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Your answer
Do you or your family members receive any state benefits such as houing assistance, food stamps, welfare, etc.? If so, please list each amount received.
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Your answer
List any other sources of income and the amounts such as unemployment compensation, SSI disability, retirement, pension, military pension or self employed income.
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Your answer
Are you married?
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Yes
No
What is your spouse's income? Please list if this is weekly, biweekly, monthly, or yearly.
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Your answer
If you are separated, pending a divorce, does the other spouse contribute anything to your household expenses? If yes, please list the amount for each.
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Your answer
If the other spouse is not ordered to pay child support yet, is he/she contributing anything to the support of children in your household? If yes, please list the amount for each.
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Your answer
Does anyone else contribute to your household income? If so, please list the contributor and the amount.
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Your answer
How many people live in your household? Please list their names and ages.
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Your answer
Are there any dependents living in your home that you financially support? If yes, please list the names and amount you contribute.
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Your answer
Do you own a home?
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Yes
No
How much do you owe on your home?
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Your answer
What is your monthly mortgage or rent payment?
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Your answer
Please list your checking and saving accounts and the current balance in each account.
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Your answer
Please list any other assets or property, including real estate, jewelry, notes, bonds, or stocks you own.
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Your answer
Please list any court ordered child support you pay.
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Your answer
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