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DOUGLAS COUNTY SUPERIOR COURT PAUPER’S AFFIDAVIT / APPLICATION Comes now, the Petitioner, being first duly sworn, deposes and says: 1. That I, by reason of my poverty, am unable to pay the cost deposit required by O.C.G.A. 15-6-77 to file a civil case, in the Courts of Douglas County. 2. That I am _______years of age, and my household income is Copies of my last two pay stubs/unemployment checks are attached. 3. That I hereby request that I be able to proceed in this action without having to pay filing fees and associated costs. Name: Address: Phone: Gross income from all sources Employment If not employed, date of last employment Usual occupation If disabled, state reason Dependants living with you and ages That I pay the following bills each month (Name of Bill & Amount). Dependants that are you are presently paying: Child Support – Amount Housing – Buying Housing – Rent Vehicles Other: By my signature below, I swear under penalty of perjury that the information contained herein is true and based upon my personal knowledge. Signature Notary