In the Superior Court of County, Georgia. 1. AFFIANT S NAME: Age. Spouse s Name:

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In the Superior Court of County, Georgia, Plaintiff vs. Civil Action No., Defendant TIC FINANCIAL RELATIONS AFFIDAVIT FINANCIAL AFFIDAVIT 1. AFFIANT S NAME: Age Spouse s Name: Age Names and birth dates of affiant s children: Name Date of Birth 2. SUMMARY OF AFFIANT S INCOME AND NEEDS (a Gross monthly income (from item 3A (b Net monthly income (from item 3B 3C Average (c Average monthly monthly expenses expenses (item 5A (item 5A Monthly payments to creditors Total monthly expenses and payments to creditors (item 5C + 1

(3A AFFIANT S GROSS MONTHLY INCOME (All income must be entered based on monthly average regardless of date of receipt Salary Wages ATTACH COPIES OF 2 MOST RECENT WAGE STATEMENTS Commissions, Fees, Tips Income from self-employment, partnership, close corporations, and independent contracts (gross receipts minus ordinary and necessary expenses required to produce income Rental Income (gross receipts minus ordinary and necessary expenses required to produce income Bonuses Overtime Payments Severance Pay Recurring Income from Pensions or Retirement Plans Interest and Dividends Trust Income Income from Annuities Capital Gains Social Security Disability or Retirement Benefits Workers Compensation Benefits Unemployment Benefits Judgments from Personal Injury or Other Civil Cases Gifts (cash or other gifts that can be converted to cash Prizes/Lottery Winnings Alimony and maintenance from persons not in this case Assets which are used for support of family Fringe Benefits (if significantly reduce living expenses Any other income (do NOT include means-tested Public assistance, such as TANF or food stamps GROSS MONTHLY INCOME 2

(3B Affiant s Net Monthly Income from employment (deducting only state and federal taxes and FICA _ Affiant s pay period (i.e., weekly, monthly, etc. Number of exemptions claimed 4. ASSETS Description Value Separate Asset of the Husband Separate Asset of the Wife Basis of the Claim Cash Stocks, bonds CD s/money Market Accounts Bank Accounts (list each account: Retirement Pensions, 401K, IRA, or Profit Sharing Money owed you: Tax Refund owed you: Real Estate: home: debt owed: other: debt owed: Automobiles/Vehicles: Vehicle 1: debt owed _ Vehicle 2: debt owed 3

Life Insurance (net cash value: Furniture/furnishings: Jewelry: Collectibles: Other Assets: Total Assets: (5A AVERAGE MONTHLY EXPENSES HOUSEHOLD Mortgage or rent payments Cable TV Property taxes Misc. household and grocery Items Homeowner/Renter Insurance Meals outside the home Electricity Other Water AUTOMOBILE Gasoline Garbage and Sewer Auto Repairs Telephone: residential line: Auto tags and license cellular telephone: Insurance Gas OTHER VEHICLES (boats, trailers, RVs, etc. Gasoline and oil Repairs and maintenance: Repairs Lawn Care Tags and license Pest Control Insurance 4

CHILDREN S EXPENSES AFFIANT S OTHER EXPENSES Child care (total monthly cost Dry cleaning/laundry School tuition Clothing Tutoring Medical, dental, prescription (out of pocket/uncovered expenses Private lessons (e.g., music, dance Affiant s gifts (special holidays School supplies/expenses Entertainment Lunch Money Recreational Expenses (e.g., fitness Other Educational Expenses (list Vacations Travel Expenses for Visitation Publications Allowance Dues, clubs Clothing Religious and charities Diapers Pet expenses Medical, dental, prescription (out of pocket/uncovered expenses Grooming, hygiene Alimony paid to former spouse Child support paid for other children Gifts from children to others Entertainment Other (attach sheet Activities (including extra-curricular, school, religious, cultural, etc. Summer Camps TOTAL ABOVE EXPENSES OTHER INSURANCE Health Child(ren s portion: Dental Child(ren s portion: Vision Child(ren s portion: Life Relationship of Beneficiary: Disability Other (specify: 75

B. PAYMENTS TO CREDITORS To Whom: Balance Due Monthly Monthly Payment TOTAL MONTHLY PAYMENTS TO CREDITORS: (5C TOTAL MONTHLY EXPENSES: This day of, 20. Notary Public Affiant 6

STATE OF GEORGIA COUNTY OF AFFIDAVIT AND MOTION TO PROCEED IN FORMA PAUPERIS I, -->, the undersigned, having been duly sworn, hereby state as follows: That I am the plaintiff in the above and foregoing case and thereby responsible for payment of fees and court costs. I am presently years of age and have been'unable to engage in substantial gainful employment since._' My total monthly income is as follows: I do not own any assets, bank accounts, stocks, bonds or other valuable property. If I am required to pay the costs of this case I will not be able to prosecute my case due to lack of funds. I believe and state that I have a meritorious claim and desire to proceed in forma pauperis. SWORN TO and SUBSCRIBED BEFORE ME, this day of -', 20=---_---: NOTARY PUBLIC My Commission Expires: 7

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