Mississippi Affidavit of Indigency Form

IN THE CIRCUIT COURT OF LINCOLN COUNTY, MISSISSIPPI

STATE OF MISSISSIPPI VERSUS CAUSE NO:__________________ ______________________________

AFFIDAVIT OF INDIGENCY Before me, the undersigned officer of said court, this came personally and Appeared ____________________________, defendant, who by me first duly sworn, states on oath the following: 1. That he/she is employed/unemployed 2. That he/she earns $___________per week/per month. 3. That he/she owns a _______________________ automobile with/without encumbrance_____________________________________. 4. That he/she owns other property listed with/without encumbrance_________________________________________________. 5. That he/she is married/unmarried and has _________ children. 6. That he/she has $_________ in checking account/$___________ in savings account. Further, by reason of poverty he/she is unable to employ counsel. Affiant understands that any false statement made in the affidavit could subject him/her to prosecution for perjury and/or contempt of court. ______________________________________ AFFIANT Sworn to and subscribed before me this the _____ day of ________________ , 2013. ______________________________________ DUSTIN R. BAIRFIELD, CIRCUIT CLERK