IN THE 16th JUDICIAL CIRCUIT COURT, JACKSON COUNTY, MISSOURI

Judge or Division: Case Number:

Petitioner: Petitioners Address/Telephone:

SSN:
VS.
Respondent: Respondents Address/Telephone:

SSN: (Date File Stamp)

Motion and Affidavit in Support of Request to Proceed As a Poor Person

Marital Status: If Married, Spouses name: Number of dependents:

(Include Spouses Income and Expenses if Married)

Monthly Income Monthly Expenses

Gross salary (before deductions) $ __________________ Mortgage Rent Payment $ _______________
Public assistance $ __________________ Utilities $ _______________
Retirement/Pension $ __________________ Food $ _______________
Social Security $ __________________ Payment on debts & credit cards $ _______________
Child Support $ __________________ Child Support $ _______________
Maintenance $ __________________ Maintenance $ _______________
Other income to be considered $ __________________ Medical expenses to be considered $ _______________
__________________________ ____________________________

Total Monthly Income $ _________________ Total Monthly Expenses $ _______________

Assets Debts
Cash on Hand $ ______________ Home loan balance $ _______________
Bank Accounts: $ ______________ Automobile loan(s) $ _______________
Checking $ ______________ Credit card balance(s) $ _______________
Savings $ ______________ Other debts to be considered $ _______________
Approximate value of home $ ______________ ______________________ $ _______________
And/or other real estate $ ______________ ______________________ $ _______________
Approximate value of automobile(s) $ ______________ ______________________ $ _______________
(1) yr/make ______________ ______________________ $ _______________
(2) yr/make ______________ ______________________ $ _______________
Approximate value of personal ______________________ $ _______________
Possessions (list)
_________________________ $ ______________
_________________________ $ ______________
_________________________ $ ______________

Total Assets $ ______________ Total Debts $ _______________

1 of 2 Rule 77.03, Section 514.040 RSMo

I swear/affirm under penalty of perjury that these facts are true to my best knowledge and belief.

__________________________________________ _____________________________________________
Date Your Signature

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 in 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

2 of 2 Rule 77.03, Section 514.040 RSMo