IN THE THIRD JUDICIAL DISTRICT
SHAWNEE COUNTY, KANSAS
Plainti
Defendant
POVERTY AFFIDAVIT
In the district court of Shawnee County; I do solemnly swear that the claim set forth in the petition
herein is just, and I do further swear that, by reason of my poverty, I am unable to pay a docket fee.
My income and assets are as follows:
Current monthly income: 4 0 e Checking com BaNKe} America
Savings account: Cash;
Home equity: Ay ONE
Estimated automobile value: os VLE
Other pertinent financial information: AMNE
VERIFICATION
Under penalty of perjury, I certify that the above information and statements are true to the best of
my knowledge.