Fillable Affidavit (West Virginia Supreme Court of Appeals)

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Affidavit (West Virginia Supreme Court of Appeals)

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BROWSE WEST VIRGINIA SUPREME COURT OF APPEALS (WV) FORMS

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SCA-C&M201: Financial Affidavit and Application
Revision Date: 12/14/2016; WVSCA Approved Date: 03/23/2011; Docket Code(s): MCMWF
Page 1 of 3
IN THE COURT OF COUNTY, WEST VIRGINIA
Plaintiff or Petitioner
v.
Defendant or Respondent
Case No.
FINANCIAL AFFIDAVIT AND APPLICATION:
ELIGIBILITY FOR WAIVER OF FEES, COSTS, OR SECURITY IN A CIVIL OR DOMESTIC CASE
OR FOR COSTS ASSOCIATED WITH
REQUIRED POLYGRAPH EXAMINATION OR ELECTRONIC MONITORING
1. You will be allowed to file and carry on your civil proceeding without giving security or paying fees or costs that
would otherwise be required, if the court finds that you meet the official financial guidelines.
2. You must complete the affidavit for the court to determine if the costs of either a polygraph examination, required
by W.Va. Code § 62-11D-2, or electronic monitoring, required by W.Va. Code § 62-11D-3, will be paid by the
supervising entity.
3. You must file a separate affidavit and application anytime your financial situation no longer meets the official
guidelines or anytime the court orders you to do so.
4. You must attach a copy of your most recent salary stub, W-2 form, or other financial documentation (with all social
security numbers and all dates of birth removed [you can black them out]) that verifies your income. Without the
attached documentation, your application will be incomplete and not considered.
5. At any time you may request or the court may require review of your eligibility for a waiver; and at any time the
court may require you to pay fees or costs previously waived or to pay future fees or costs.
6. When you sign this form, you will have to swear or affirm that you have completely and truthfully provided all
information sought, to the best of your knowledge and ability. If you knowingly give any incomplete and/or false
information, you may be prosecuted for the crime of false swearing.
7. The information you give in this form will be confidential only in a domestic violence or a divorce case.
8. Except for signatures, all information must be clearly printed.
A. Information for the Applicant:
B. Information about You and Your Case:
1a. Name:
1c. Address:
1b. Telephone Number:
SCA-C&M201: Financial Affidavit and Application
Revision Date: 12/14/2016; WVSCA Approved Date: 03/23/2011; Docket Code(s): MCMWF
Page 2 of 3
2. Describe what is involved in your case:
Case No.
.
No3a. Do you have a lawyer? Yes
4. Check if seeking waiver for:
Cost of required polygraph examination (W.Va. Code § 62-11D-2); and/or
Cost of required electronic monitoring (W.Va. Code § 62-11D-3).
b. Have you paid or will you have to pay your lawyer?
c. Will you have to pay your lawyer only if you win?
NoYes
NoYes
C. Information about Your Financial Situation:
1a. What is your current yearly net (take-home) income from all sources:
Employer: $
Second Job:
$ Self-Employment: $
Public Assistance: $
Food Stamps:
$ Unemployment: $
Benefits: $
Disability Benefits:
$ Social Security/SSI: $
Alimony: $
Pensions:
$ Rental Income: $
Interest: $
Dividends:
$ Annuities: $
Odd Jobs: $ Other: $ (specify):
YEARLY TOTAL: $
1b. If your listed income is zero (0), please explain below and attach some verification (i.e. DHHR or food stamp
information):
Please remember to attach financial documents which verify this information.
2a. List the names and relationships to you of all the persons supported by this income, whether or not they are
household members (provided, that these persons can be claimed as dependents on your federal tax return):
and/or bonds (liquid assets)? $
2b. What is the total number of dependents, including yourself ?
.
.
3. How much money do you, individually or jointly, have in cash, checking and savings accounts, deposit certificates,
SCA-C&M201: Financial Affidavit and Application
Revision Date: 12/14/2016; WVSCA Approved Date: 03/23/2011; Docket Code(s): MCMWF
Page 3 of 3
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,
own.
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
Case No.
Mortgage/Rent: $ Car Payment: $ Loan Payments: $
Credit Card Payments: $ Other Debt Payments: $ Utilities: $
Cell Phone: $ Food: $ Child Care: $
Child Support: $
Alimony:
$ 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:
Date:
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Affidavit (West Virginia Supreme Court of Appeals)

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Completed 27 July 2020

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