SOUTHERN JUDICIAL CIRCUIT

ALTERNATIVE DISPUTE RESOLUTION PROGRAM

STYLE:                                                                                                                                                                       

THE UNDERSIGNED, BEING FIRST DULY SWORN ON OATH, DEPOSES AND SAYS:

I am financially unable to obtain the service of a Neutral to hear my Alternative Dispute Resolution Session without causing substantial hardship to myself or to my family; the following information is true and is given and intended to be relied upon by the Administrator of the Southern Judicial Circuit ADR Program in determining my eligibility for the assistance of a Neutral to be furnished at the expense of the Southern Judicial Circuit ADR Program.

I. GENERAL INFORMATION

    (1) Name:                                                                                                                                                      

    (2) Address:                                                                                                                                                  

    (3) Social Security No.:                                                       (4) Birth Date:                                                        

    (5) Number of Dependent Children:                     (6)           Divorced           Separated          Married           Single

II. INCOME AND ASSETS

    (1) Weekly income (Take-Home)                                                                                                                      

    (2) Employer or other source of income (including government agency)                                                                

    (3) If unemployed, name of last employer, and date of termination                                                                       

    (4) Monthly or weekly income of spouse or dependents                                                                                      

    (5) Employer or other source of spouse's income (including government agency)                                                  

    (6) Home or other real estate: Value                                                Equity                                                        

    (7) Automobiles                                                                                                                                              

    (8) Other assets or property                                                                                                                             

                     (c) Savings Accounts                                                    (d) Safe Deposit Box                                  

III. EXPENSES AND DEBTS

    (1) Rent or Mortgage                                 (2) Food                                     (3) Utilities                                   

    (4) Transportation                                      (5) Installment Payments                                                               

    (6) Medical and Dental                                (7) Insurance, i.e., (Auto, Home)                                                   

    (8) Child Care, i.e., Day Care for Working Mothers                                                                                          

NAME OF CREDITOR - AMOUNT OWED                                     NAME OF CREDITOR - AMOUNT OWED

 
I declare under penalty of perjury that the foregoing is true and correct; I am aware that perjury is a felony punishable by a fine of not more than $1,000.00 or imprisonment for not less than one year, nor more than 10 years.

         READ, DATED AND SIGNED, this              day of                                                                    , 20           .

                                                                                   Alternative Dispute Resolution Participant

this               day of                                                               , 20              .

 

The above and foregoing application read and considered, the above named Alternative Dispute Resolution Participant IS/IS NOT indigent within the guidelines set by the Superior Court Judges of the Southern Judicial Circuit, and the Alternative Dispute Resolution Program WILL/WILL NOT pay the fees for the Neutral.

          This                day of                                                                           , 20            .

                                                                                  Tim C. Hendrick, Administrator
                                                                                  Alternative Dispute Resolution Program
                                                                                  Southern Judicial Circuit

County:                                                                                      

File Name:                                                                                 

File No.:                                                                                     

Neutral: