Commonwealth of Massachusetts
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.)
Case Name and Number (if known)
(Street and number) (City or town) (State and Zip)
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)
Emergency Aid to Elderly, Disabled or Children (EAEDC)
Massachusetts Veterans Benefits Programs; or
Supplemental Security Income (SSI)
(B) My income, less taxes deducted from my pay, is
(check the period that applies)
persons, consisting of myself and
which income is at or below the court system's poverty level; (Note: The court system's poverty levels for households
of various sizes must be posted in this courthouse. If you cannot find it, ask the clerk or check online at:
http://www.mass.gov/courts/sjc/docs/povertyguidelines.pdf. The court system’s poverty level is updated each year.)
(List any other available household income for the checked period on this line: $
(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.