IMPOUNDED - CONFIDENTIAL

COMMONWEALTH OF MASSACHUSETTS

 Court

NO.

INFORMATION FOR THE INMATE/APPLICANT: You have requested that the 

 Court waive the filing fees and (normal) costs and allow you to proceed as an indigent

plaintiff.  You are required to provide the court with information about your finances so that the court can
determine whether you are unable to pay the fee or to make partial payments.  You are required to sign this
affidavit form under the penalties of perjury.  This includes a statement that no action has been taken to hide
assets.  The court can dismiss the complaint if it finds that the claim of indigency is untrue.  In addition, the court
may impose costs on an inmate who intentionally files an affidavit that contains false information or that omits
material information.  You are also subject to loss of up to 60 days of good time earned or to be earned under
G. L. c. 127, § 129C ( for blood donation) or under c. 127, § 129D (for work, education or rehabilitation
programs) if the court finds that the affidavit is frivolous and filed in bad faith in order to abuse the judicial
process.  See G. L. c. 261, § 29.

v.

,

,

Plaintiff(s)

Defendant(s)

INMATE'S AFFIDAVIT OF INDIGENCY AND REQUEST FOR WAIVER OF NORMAL FEES AND

COSTS IN COMPLIANCE WITH GENERAL LAWS c. 261, § 29

Pursuant to General Laws c. 261, § 29, the applicant, 

the following information is true.

(NAME)

, swears (or affirms) that

SOCIAL SECURITY #:

DATE OF BIRTH:

INMATE IDENTIFICATION #:

CORRECTIONAL FACILITY:

ASSETS:

CASH:

MONIES IN BANK ACCOUNTS:

INMATE CANTEEN ACCOUNT:

OTHER INSTITUTIONAL ACCOUNT:

NON-PRISON ACCOUNT(S):

REAL ESTATE:

OTHER INVESTMENTS:

ACCESSIBLE ASSETS OF A SPOUSE:

INCOME:

LAST SIX MONTHS' INCOME:

INCOME EXPECTED IN NEXT SIX MONTHS:

LIABILITIES (for example, any debts you owe, including Victim/Witness fees, restitution fees, child support,
other court-imposed costs, and costs assessed for incarceration and pre-release programs):

NECESSARY CANTEEN PURCHASES (for example, stamps, envelopes, soap, toothpaste and other

toiletries, medications and clothing):

MONTHLY EXPENSES:

OTHER EXPENSES:

I state under penalties of perjury that the statements made in this affidavit are true, that I have not omitted any

assets that are available to me to pay filing fees or court costs, that I have not transferred any assets to avoid
payment of filing fees and costs, and that I have not taken any action nor has any action been taken on my behalf
relative to any assets in order to avoid having such assets used for payment of filing fees and costs.

Signature of applicant: _____________________________________________

DATE:

ALL INFORMATION CONTAINED HEREIN IS CONFIDENTIAL.  EXCEPT BY SPECIAL ORDER

OF A COURT, IT SHALL NOT BE DISCLOSED TO ANYONE OTHER THAN AUTHORIZED COURT
PERSONNEL, PARTIES TO THIS LITIGATION OR THEIR COUNSEL, AND AN AUTHORIZED (IN
WRITING) REPRESENTATIVE OF THE APPLICANT.