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SUPERIOR COURT OF ______________ COUNTY
STATE OF GEORGIA
Case No. ______________
Affidavit of Indigency
I, _____________________________, having first been duly sworn, depose and state under oath
as follows:
1. Affiant Information
a. Name: _________________________________________
b. Address: _______________________________________
c. Date of Birth: __________________ Employment Status: ______________________
2. Statutory Basis
This Affidavit is made pursuant to O.C.G.A. § 9-15-2, which authorizes the waiver of
court fees and costs for persons unable to pay.
3. Dependents
I support the following dependents who reside with me:
4. Monthly Gross Income
a. Wages/Salary (gross): $______________
b. Public benefits (e.g., Social Security, TANF, SNAP): $______________
c. Child support/alimony: $______________
d. Other income (describe): __________________________ $______________
Total Monthly Gross Income: $______________
5. Monthly Expenses
a. Rent or Mortgage: $______________
b. Utilities (electricity, water, gas, phone, internet): $______________
c. Food: $______________
d. Transportation (car payment, fuel, public transit): $______________
e. Medical (insurance premiums, prescriptions): $______________
f. Other debts (loans, credit cards): $______________
Total Monthly Expenses: $______________
6. Assets
a. Cash on hand: $______________
b. Bank accounts (list institutions and balances):
• __________________________: $
• __________________________: $
c. Real property (address and approximate value):
• __________________________: $
d. Vehicles (make, model, year, approximate value):
• __________________________: $
e. Other assets (investments, personal property):
• __________________________: $
7. Inability to Pay
I certify that I am unable to pay the filing fees, service fees, or other court costs in this
action without substantial hardship to myself and my dependents.
WHEREFORE, I respectfully request that the Court waive all filing fees, service fees, and other
court costs in this matter pursuant to O.C.G.A. § 9-15-2.
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Signature of Affiant: ______________________________
Printed Name: ____________________________________
Date: 5/18/2025
Sworn to and subscribed before me
this ___ day of May, 2025.
Notary Public, State of Georgia
My Commission Expires: _________________
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