THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services 200
Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606
MASS.GOV/CJIS
AffidavitofIndigency
(ToBeSubmittedwithPersonalRequestForm)
Youoryourclient(ifyouaresubmittingapersonalCORIrequestonbehalfofaclient),maybeeligibleforawaiverofCORIrequest
fee.Inordertoapply,pleasecompletethisaffidavitofindigency.Pleasenote,youmustselecttheoptionbelowthatmostclosely
describesyouoryourclient'sfinancialstatus.
RequestorDetails
Pleasetypeorprintclearly.Itemsmarkedwithanasterisk(*)MUSTbecompleted.
* FirstName: _______________________________________________________ MiddleInitial: _________________________
* LastName: _______________________________________________________ Suffix(Jr.,Sr.,etc): _____________________
* StreetAddress:____________________________________________________________________________________________
Apt. # or Suite: ______________ *City: __________________________ *State: __________ *Zip:_______________
IndigencyDetails
*PursuanttoM.G.L.c.6,§172A,Iswear(oraffirm)asfollows:IAMINDIGENTinthat:(select"yes"toatleastoneoption)
1. Doyoureceivepublicassistance?
Yes No
Ifyes,selecttheprogramsyoureceiveassistancefrom:
MassachusettsTransitionalAidtoFamilieswithDependentChildren(TAFDC)
FederalSupplementSecurityIncome(SSI)
EmergencyAidtoElderly,DisabledandChildren(EAEDC)
Medicaid(MassHealth)
MassachusettsVeterans'Programs
2. Is your income 125% or less of the current poverty threshold published in the Federal Register by the U.S.
DepartmentofHealthandHumanServices?
Yes No
My income, less taxes deducted from my pay is $ _______ per_________, for a household of ____persons
consisting of myself and _____ dependants. I have other available household income for the selected period of
$______
3. CanyoupaytheCORIfeewithoutdeprivingyourselforyourdependentsofthenecessitiesoflife?
Yes No
Ifyes,youmustcompletetheseboxes:
GrossMonthlyIncome:______________GrossIncomeforthePastTwelveMonths: _______________________
If employed,pleaselistyouroccupationandemployer’snameandaddress: _____________________________
____________________________________________________________________________________________
Ifunemployed,pleaselistyoursourceofincome:_________________________________________________
4. Areyoucurrentlyincarcerated?
Yes No
IrequestthattheDepartmentofCriminalJusticeInformationServiceswaivethefeeforaPersonalCriminalRecord
Information(CORI)requestunderpenaltyofperjury.
___________________________________________________________________
SignatureofIndividualMakingCORIRequest
____________________________
Date
click to sign
signature
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