The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02

LIT Lab Home | About The Explorer | Find & Compare | Explore: Massachusetts Lists

Here is the text we could read:

Commonwealth of Massachusetts

AFFIDAVIT OF INDIGENCY

AND REQUEST FOR WAIVER, SUBSTITUTION 

OR STATE PAYMENT OF FEES & COSTS

(Note:  If you are currently confined in a prison or jail and are not seeking immediate release under G.L. c. 248 §1, but 
you are suing correctional staff and wish to request court payment of “normal” fees (for initial filing and service),  do not 
use this form.  Obtain separate forms from the clerk.)

Court

Name of applicant:

Address:

Case Name and Number (if known)

(Street and number)

(City or town)

(State and Zip)

SECTION 1: Under the provisions of General Laws, Chapter 261, Sections 27A-27G, I swear (or affirm) as follows: 

I AM INDIGENT in that (check only one ):

(A) I receive public assistance under (check form of public assistance received):

  Transitional Aid to Families with Dependent Children (TAFDC)

  Medicaid (MassHealth)

  Emergency Aid to Elderly, Disabled or Children (EAEDC)

  Supplemental Security Income (SSI)

  Massachusetts Veterans Benefits Programs; or

(B) My income, less taxes deducted from my pay, is  $ 
(check the period that applies)  for a household of 
which income is at or below the court system's poverty level; (Note: The court system's poverty levels for households 

persons, consisting of myself and 

biweekly  month 

  dependents; 

per  week 

year

of various sizes must be posted in this courthouse.  If you cannot find it, ask the clerk or check online at:

https://www.mass.gov/doc/poverty-threshold-guidelines/download.  The court system’s poverty level is updated each 

year.)(List any other available household income for the checked period on this line: $ 

); or

(C) I am unable to pay the fees and costs of this proceeding, or I am unable to do so without depriving myself

or my dependents of the necessities of life, including food, shelter and clothing.

IF YOU CHECKED (C), YOU MUST ALSO COMPLETE THE SUPPLEMENT TO THE AFFIDAVIT OF 
INDIGENCY.

SECTION 2:  

(Note: In completing this form, please be as specific as possible as to fees and costs known at the time of 
filing this request.  A supplementary request may be filed at a later time, if necessary.)

I request that the following NORMAL FEES AND COSTS be waived (not charged) by the court, or 
paid by the state, or that the court order that a document, service or object be substituted at no cost (or a  
lower cost, paid for by the state): (Check all that apply and, in any "$____" blank, indicate your best  
guess as to the cost, if known.)

  Filing fee and any surcharge. $

  Filing fee and any surcharge for appeal.  $

  Fees or costs for serving court summons, witness subpoenas or other court papers.  $

  Other fees or costs of  $

for  (specify):

  Substitution (specify):

SECTION 3: 

I request that the following EXTRA FEES AND COSTS either be waived (not charged), substituted or  
paid for by the state:

  Cost,  $

,  of expert services for testing, examination, testimony or other assistance (specify):

 Cost,  $

, of taking and/or transcribing a deposition of (specify name of person):

Cassette copies of tape recording of trial or other proceeding, needed to prepare appeal for applicant not
represented by Committee for Public Counsel Services (CPCS-public defender).

Appeal bond

 Cost,  $

, of preparing written transcript of trial or other proceeding

  Other fees and costs,  $

, for  (specify):

  Substitution (specify)

Date signed

Signed under the penalties of perjury

x 

By order of the Supreme Judicial Court, all information in this affidavit is CONFIDENTIAL.  Except by special 
order of a court, it shall not be disclosed to anyone other than authorized court personnel, the applicant, 
applicant's counsel or anyone authorized in writing by the applicant.

This form prescribed by the Chief Justice of the SJC pursuant to G.L. c. 261,  § 27B.  Promulgated March   , 2003.   
Fillable PDF created August 2013.

Affidavit of indigency

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Massachusetts state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.mass.gov (2023-03)
Page(s): 2
Fields(s): 50
Average fields per page: 25
Reading Level: Grade 11
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

court was Court (0.65 conf)
case_name_number_known was Case Name and Number if known (0.40 conf)
name_applicant was Name of applicant (0.37 conf)
street_number was Street and number (0.45 conf)
city_town was City or town (0.33 conf)
state_zip was State and Zip (0.34 conf)
public_assistance_check was A I receive public assistance under check form of public assistance received (0.51 conf)
aid_families_dependent was Transitional Aid to Families with Dependent Children TAFDC (0.34 conf)
aid_elderly_disabled was Emergency Aid to Elderly Disabled or Children EAEDC (0.38 conf)
veterans_benefits_programs was Massachusetts Veterans Benefits Programs or (0.41 conf)
medicaid_mass_health was Medicaid MassHealth (0.43 conf)
supplemental_income_ssi was Supplemental Security Income SSI (0.41 conf)
persons_consisting was persons consisting of myself and (0.40 conf)
week was week (0.37 conf)
biweekly was biweekly (0.32 conf)
month was month (0.28 conf)
year was year (0.28 conf)
check_applies_household was check the period that applies for a household of (0.41 conf)
income_level_levels_households was which income is at or below the court systems poverty level Note The court systems poverty levels for households (0.36 conf)
available_household_income was List any other available household income for the checked period on this line (0.32 conf)
b was B (0.34 conf)
c was C (0.34 conf)
cost_paid_state_check_apply was lower cost paid for by the state Check all that apply and in any (0.43 conf)
guess_cost_known was guess as to the cost if known (0.38 conf)
filing_fee_surcharge was Filing fee and any surcharge (0.39 conf)
filing_fee_surcharge_appeal was Filing fee and any surcharge for appeal (0.44 conf)
fees_costs_court was Fees or costs for serving court summons witness subpoenas or other court papers (0.42 conf)
fees_costs__1 was Other fees or costs of (0.35 conf)
substitution_specify__1 was Substitution specify (0.46 conf)
undefined__1 was undefined (0.38 conf)
undefined__2 was undefined_2 (0.39 conf)
undefined__3 was undefined_3 (0.39 conf)
specify__1 was for specify (0.30 conf)
undefined__4 was undefined_4 (0.39 conf)
cost__1 was Cost (0.36 conf)
testing_assistance_specify was of expert services for testing examination testimony or other assistance specify (0.36 conf)
cost__2 was Cost_2 (0.26 conf)
taking_specify_person was of taking andor transcribing a deposition of specify name of person (0.43 conf)
undefined__5 was undefined_5 (0.39 conf)
trial_proceeding_applicant was Cassette copies of tape recording of trial or other proceeding needed to prepare appeal for applicant not (0.38 conf)
appeal_bond was Appeal bond (0.46 conf)
cost__3 was Cost_3 (0.26 conf)
transcript_trial_proceeding was of preparing written transcript of trial or other proceeding (0.46 conf)
undefined__6 was undefined_6 (0.39 conf)
specify__2 was for specify_2 (0.39 conf)
fees_costs__2 was Other fees and costs (0.35 conf)
substitution_specify__2 was Substitution specify_2 (0.44 conf)
undefined__7 was undefined_7 (0.39 conf)
date_signed was Date signed (0.42 conf)
x was x (0.34 conf)

Create an Interactive Version of this Form:

The Weaver creates a draft guided interview from a template form, like the one provided here. You can use the link below to open this form in the Weaver. To learn more, read "Weaving" your form into a draft interview.

Launch Form in Weaver

The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Affidavit of indigency

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02