<p> DEPENDENCY/NEGLECT AFFIDAVIT OF INDIGENCY Parent/Guardian Name: ______Case No. ______Employment: Are you currently employed? ___Yes ___ No If yes, name employer: ______And what is your take home pay? $______/ per month ______Marital Status: _X_ Single ___ Married ___ Separated ___ Divorced If married and not separated, is your spouse employed? ___ Yes ___ No If yes, name employer: N/A And what is his/her take home pay? $______/ ___ per week ___ per two weeks ___ per month Provide names, ages and relationship of all the people who live in your home and for whom you provide support: Name Relationship Age</p><p>Household Assets: If you or anyone in the house has cash on hand or money in an account, list the amount: CASH $______CHECKING ACCT $______SAVINGS ACCT $______</p><p>Other Income Sources: List the amount of money that you or anyone living in the house currently receives from other sources: TEA $______Food Stamps $______Unemployment Compensation $______Social Security or SSI $______Child Support $______Rental Property $______Workers Compensation or Disability $______Pension or Retirement $______Gifts or Inheritances $______Other $______</p><p>MONTHLY AVERAGE BUDGET: ___ Rent ___ Mortgage: $______Food $______Utilities $______Day Care $______Child Support $______Clothing $______Medical Expenses $______Vehicle Payments (car, van, motorcycle, etc.) $______Transportation (gas, bus) $______Insurance (medical, property, vehicle, life) $______Credit Cards $______TOTAL MONTHLY BUDGET: $______</p><p>I understand that a false statement or answer to any question may subject me to prosecution for perjury with possible punishment and I state under oath that this information is true and correct to the best of my knowledge and recollection. I will report immediately any change in my financial condition to the court and to my attorney. ______DATE Parent/Guardian Signature</p><p>SWORN TO AND SUBCRIBED BEFORE ME on this _____ day of ______, ______. ______Notary Public My Commission Expires: ______</p>