STATE OF NEW MEXICO
COUNTY OF ___________________________
SIXTH JUDICIAL DISTRICT COURT

_____________________________, Petitioner,

v.                                    No. ___________

_____________________________, Respondent

    Pursuant to LR6-108 NMRA, I ________________________ (name of party), request that the court enter an order permitting me to file this case without prepayment of fees and costs and state upon my oath or affirmation the following statement regarding my financial, marital and employment status:
    A.     Background and Residence
        1.    Full name: ________________________________
        2.    Age: ________________________________
        3.    Sex: ________________________________
        4.    Present address: ___________________________
            _____________________________________________
        5.    How long at this address? _________________
        6.    Phone number: ____________________
        7.    Married ___ Single ___ Divorced ___
            Separated ___
        8.    Number of dependents: _____________________
        9.    Ages of children living with you: ___________

            ___________________________________________
        10.    List name and relationship of other dependents living with you: ________________
            ____________________________________________
        11.    List any dependents in items 7 and 8 depending on you for your support:
            ________________________________
    B.     Employment and income
        1.    Are you employed? __________
            Are you self-employed? ______________
        2.    Name and address of employer:
            ________________________________
            ________________________________
        3.    Position: ______________________
            Salary per month: _________________
        4.    If self-employed, nature of business:
            ____________________________________
        5.    Income previous month from self-employment:
            $_____________________.
        6.    If unemployed, how long since last job or self-employment? __________________________
        7.    Any other income including, but not limited to, disability pay, workman's compensation, social security, pension, interest, note and loan repayments, dividends, trust funds and

unemployment compensation? [ ] Yes [ ] No.
        8.    If the answer to 7 is yes, list each source and amount per month from each source:
            __________________    $______________________
            __________________    $______________________
        9.    Total monthly net income: _______________
            ______________________________________.
    C.     Assets
        1.    Do you own any real estate?
            Yes [ ]     No [ ]
            a.    Description __________________________
            b.    Location _____________________________
            c.    Estimated present value ______________
            d.    Estimate outstanding mortgages or contracts on property _______________
                _____________________________________
            e.    Payments per month: ________________
        2.    Do you own any automobiles? Yes [ ] No [ ]
            a.    Make ________ Model _____ Year _____
            b.    Present Value: ________
                Total amount owed $________________
            c.    Monthly payments _________________
        3.    Do you have any stocks or bonds?
            Yes [ ]    No [ ]
            a.    Describe ________________________

            b.    Present value: ________________
        4.    Do you have any cash in the bank?
            Yes    [ ]    No [ ]
            a.    If so, indicate amount: _______________
        5.    Do you have any cash in a savings and loan association? Yes [ ]    No [ ]
        6.    Do you have any other assets not listed above excluding household furnishings and clothing?    Yes [ ] No [ ]
            a.    If so, describe and give value:
                ___________________________________
    D.     Debts and other obligations
        1.    Rent: $_____________ per month.
        2.    Utilities: $____________ per month.
        3.    Creditors:
        List:            Total Due:    Monthly Payment
        ________________    ____________    _______________
        ________________    ____________    _______________
        ________________    ____________    _______________
        ________________    ____________    _______________
        4.    Total monthly payments:        $______________
E.    I have no information regarding my spouse's income and or my spouse lives out of state.

spouse:
        1.    Address: ________________________________
            __________________________________________
        2.    Employer's address: _______________________
            ___________________________________________
        3.    Income: $_________ (monthly weekly biweekly)
        4.    Resource:
            Cash (savings, etc): ______________________
            ___________________________________________
            Social Security: $_________________________
            Unemployment compensation: $_______________
            Other income: $_________________
                Describe: _____________________________
                ________________________________________
        5.    Debts:
            Mortgage or rent: $_________________________
            Utilities: $________________________________
            Other creditors: $________________________
            ____________________________________________
            ____________________________________________
    I [do] [do not] have access to my spouse's resources or income.
                        _____________________________
                        Petitioner

    SUBSCRIBED AND SWORN TO before me this ____ day of _______________, _____, by ______________________________.

                        _____________________________
                        Notary Public

My Commission Expires:
______________________

[Approved, effective October 2, 2000.]