IN THE CIRCUIT COURT OF ___     __________ COUNTY, MISSOURI

Judge or Division:      	Case Number:      	(Date File Stamp) 	
Petitioner:
     

SSN:      	vs.	Petitioner’s Address/Telephone:
     		
Respondent:
     

SSN:      	Respondent’s Address/Telephone:
     		
Motion and Affidavit in Support of Request to Proceed As a Poor Person	
Marital status:
	
If Married, Spouse’s name:
     	
Number of dependents:
  	

(Include Spouse’s Income and Expenses if Married)
Monthly Income	
	
Monthly Expenses	

Gross salary (before deductions)	
$ 	 0	

Public assistance	
$ 	 0	

Retirement/Pension	
$ 	 0	

Social Security	
$ 	 0	

Child Support	
$ 	 0	

Maintenance	
$ 	 0	

Other income to be considered	
$ 	 0	

     	

Total Monthly Income	

  0	

 Mortgage      Rent Payment	
$ 	 0	

Utilities	
$ 	 0	

Food	
$ 	 0	

Payment on debts & credit cards	
$ 	 0	

Child Support	
$ 	 0	

Maintenance	
$ 	 0	

Other expenses to be considered	
$ 	 0	

     	

Total Monthly Expenses	

  0	

	

	

Assets	
	
Debts	

Cash on hand	
$ 	 0	

Bank Accounts:	
00	

     Checking	
$ 	 0	

     Savings	
$ 	 0	

Approximate value of home	
$ 	 0	

     And/or other real estate	
$ 	 0	

Approx.value of automobile(s)	
$ 	 0	

     (1) yr/make       	
00	

     (2) yr/make       	
0	

Approximate value of personal	
00	

     possessions (list)	
00	

     	
$ 	 0	

     	
$ 	 0	

     	
$ 	 0	

	

Total Assets	
0	

Home loan balance	
$ 	 0	

Automobile loan(s)	
$ 	 0	

Credit card balance(s)	
$ 	 0	

Other debts to be considered	
0	

     	
$ 	 0	

     	
$ 	 0	

     	
$ 	 0	

     	
$ 	 0	

     	
$ 	 0	

	

	

	

	

	

	

Total Debts	
0	

	

	

ffdd

I swear/affirm under penalty of perjury that these facts are true to my best knowledge and belief.
	
_________________________________________
	Date	________________________________________________
	Your Signature	
		
Subscribed and sworn to before me on ____________________________
	Date	
		
	________________________________________________
	Clerk	

Order to Proceed as a Poor Person

  The Court, having considered the Motion and Affidavit in Support of Request to Proceed as a Poor Person, finds that 
     __________________________ is without sufficient funds or assets with which to pay the advance deposit for costs of this action and, therefore, is granted leave to proceed as a poor person and the required advanced deposit for costs is waived.

  The Court, having considered the Motion and Affidavit in Support of Request to Proceed as a Poor Person, finds that 
     __________________________ has sufficient funds or assets with which to pay the advance deposit for costs in this action, and therefore, the Motion is denied.	

	

_________________________________________
	Date	

_________________________________________
	Commissioner/Judge