Fill - Free fillable Commonwealth of Massachusetts Affidavit of Indigency PDF form

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

AffidavitofIndigency

(ToBeSubmittedwithPersonalRequestForm)

Youoryourclient(ifyouaresubmittingapersonalCORIrequestonbehalfofaclient),maybeeligibleforawaiverofCORIrequest

fee.Inordertoapply,pleasecompletethisaffidavitofindigency.Pleasenote,youmustselecttheoptionbelowthatmostclosely

describesyouoryourclient'sfinancialstatus.

RequestorDetails

Pleasetypeorprintclearly.Itemsmarkedwithanasterisk(*)MUSTbecompleted.

* FirstName: _______________________________________________________ MiddleInitial: _________________________

* LastName: _______________________________________________________ Suffix(Jr.,Sr.,etc): _____________________

* StreetAddress:____________________________________________________________________________________________

Apt. # or Suite: ______________ *City: __________________________ *State: __________ *Zip:_______________

IndigencyDetails

*PursuanttoM.G.L.c.6,§172A,Iswear(oraffirm)asfollows:IAMINDIGENTinthat:(select"yes"toatleastoneoption)

1. Doyoureceivepublicassistance?

☐ Yes ☐ No

Ifyes,selecttheprogramsyoureceiveassistancefrom:

☐ MassachusettsTransitionalAidtoFamilieswithDependentChildren(TAFDC)

☐ FederalSupplementSecurityIncome(SSI)

☐ EmergencyAidtoElderly,DisabledandChildren(EAEDC)

☐ Medicaid(MassHealth)

☐ MassachusettsVeterans'Programs

2. Is your income 125% or less of the current poverty threshold published in the Federal Register by the U.S.

DepartmentofHealthandHumanServices?

☐ 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. CanyoupaytheCORIfeewithoutdeprivingyourselforyourdependentsofthenecessitiesoflife?

☐ Yes ☐ No

Ifyes,youmustcompletetheseboxes:

GrossMonthlyIncome:______________GrossIncomeforthePastTwelveMonths: _______________________

If employed,pleaselistyouroccupationandemployer’snameandaddress: _____________________________

____________________________________________________________________________________________

Ifunemployed,pleaselistyoursourceofincome:_________________________________________________

4. Areyoucurrentlyincarcerated?

☐ Yes ☐ No

IrequestthattheDepartmentofCriminalJusticeInformationServiceswaivethefeeforaPersonalCriminalRecord

Information(CORI)requestunderpenaltyofperjury.

___________________________________________________________________

SignatureofIndividualMakingCORIRequest

____________________________

Date

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Commonwealth of Massachusetts Affidavit of Indigency

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