SCA-C&M201: Financial Affidavit and Application
Revision Date: 12/14/2016; WVSCA Approved Date: 03/23/2011; Docket Code(s): MCMWF
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4a. List your regular monthly household debt-payment and other expenses:
5a. List all cars, trucks, motorcycles, or recreational vehicles (all-terrain vehicles, motor homes, snowmobiles, boats),
including their make, model, and year, that you own, individually or jointly:
5b. What is the total value of these items less any amount owed? $
6a. List all real estate (houses, lots, land, rental property, other commercial property) that you, individually or jointly,
7. What would the consequences be for you if a waiver of fees, costs, or security is denied?
8. This application consists of three (3) pages and
pages of supporting financial documents.
By signing my name on this form, I swear to or affirm: (1) the completeness and truthfulness, to the best of my ability
and knowledge, of the information I have provided and (2) my belief that I have a right to a waiver.
Signature of Affiant-Applicant:
Taken, subscribed, and sworn or affirmed before me, by the person whose signature appears above, on this
_______ day of _________________________, 20_______, in _________________________ County, West Virginia.
Signature of Notary (Clerk or Deputy Clerk):
For Court Use Only
Mortgage/Rent: $ Car Payment: $ Loan Payments: $
Credit Card Payments: $ Other Debt Payments: $ Utilities: $
Cell Phone: $ Food: $ Child Care: $
Child Support: $
$ Medical Bills: $
Other Expenses: $ (specify):
4b. What is the total amount of these monthly expenses?
6b. What is the total value of these items less any amount owed? $
The affiant's application for a waiver is (clerk: initial one) _______________ granted _______________ denied.
Signature of Clerk or Deputy: