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STATE OF WISCONSIN MUNICIPAL COURT CITY OF RACINE
Affidavit Of Indigency (Poverty)
Under oath, I state that because of poverty, I am unable to pay the forfeiture ordered by the City of Racine Municipal Court.
I currently receive (check all that apply): Supplemental security income Food stamps/food share Benefits for veterans under §45.40(1m) or 38 USC 501-562 (subsistence aid to needy veterans) Legal representation from a civil legal services program, a public defender program, or a volunteer attorney program based on indigency. Name of Program: Relief funded under Wis. Stat. §59.53(21) (county relief programs) Relief funded under public assistance Medical assistance Other means-tested public assistance Name of Program: My financial situation has not changed since I became eligible for this program/ these programs. Income information: I am Employed Name of employer: I earn: $ Every: I receive monthly income from the following (include amounts): Pension: $ Social Security: $ Unemployment: $ Disability: $ Student loans/grants: $ Other: $ I have the following cash assets: Savings accounts: $ Checking accounts: $ Cash: $ Money owed to me: $ I have the following other assets: Vehicle: $ Real Estate: $ Other assets valued over $200: $ Household Information My household consists of myself and 0 1 2 3 4 5 6 7 8 9 10 other people I am Married Spouse’s Full Name: Full Name: Relationship to me: Full Name: Relationship to me: Full Name: Relationship to me: Full Name: Relationship to me: Full Name: Relationship to me: The other members of my household have a gross monthly income totaling the amount of: $ The other members of my household collect monthly income from the following sources: Wages Social Security Relief under public assistance Food stamps Pension Student loans/grants Unemployment compensation SSI Disability Relief funded under 59.23(21) Child support/maintenance I do not receive income from any other source because: I ask that the court also consider my unique circumstances (such as unusual debt or circumstances: I herby sign under penalty of perjury: Name: Date: [None] 
Phone Number: Address: City: State: Zipcode: Please only click the Submit button once!
