Hill County Drug/Dui Court

HILL COUNTY DRUG/DUI COURT

JUSTICE COURT, HILL COUNTY, HAVRE, MONTANA

BEFORE AUDREY BARGER, JUSTICE OF THE PEACE

** * * * * * * * * * * * * * * * * *

IN THE MATTER OF )Cause No. HCDC-__-____

______,)INDIGENCY QUESTIONNAIRE

Treatment Court Participant.)

** * * * * * * * * * * * * * * * * * *

ANSWER ALL QUESTIONS. USE N/A IF NOT APPLICABLE

STATE OF MONTANA)

: ss.

County of Hill)

I, ______, being first duly sworn, depose and say:

1, That I am ready to:

______move to Phase _____; or

______graduate from one of the Hill County Treatment Courts but

2. I am unable to pay the:

______required treatment court participant fees; or

______obtain the funds to pay for the Prime for Life Program.

3. I request the Court to waive the required participant fees or completion of the Prime for Life Program to:

______move to Phase _____; or

______graduate from one of the Hill County Treatment Courts

due to indigency.

I. PERSONAL INFORMATION:

Name ______Age ______

Address ______Telephone ______

Employed? Yes ______No ______Self-Employed? Yes______No ______

Employer’s name ______

Employer’s address ______

Month last employed ______Job ______

Single ______Married ______Divorced ______Separated ______

Dependents? Spouse’s name ______DOB ______Age ______

SSN ______Employer ______

Employer’s address ______

Are you sharing expenses with anyone? Yes ______No ______

Explain ______

Are you sharing income with anyone? Yes ______No ______

Number of children _____ Age(s) ______

II. INCOME:

Income available:

My monthly wages/salary$______AFDC $______

Other wages/salary$______Unemployment$______

Workers’ Comp$______SSI$______

Food Stamps$______Medicaid$______

Pension$______Retirement$______

Child Support$______Other Income$______

Total Household Income:

Last Month$______Previous 12 Months$______

III. ASSETS:

A.Motor Vehicle(s)?Yes ______No ______How Many? ______

Spouse’s motor vehicle(s) ______

Is/are these vehicle(s) paid for? Yes ______No ______If not, how much

do you owe?

$______Year ______Make ______Model______

B.Do you or your spouse own any land or other real estate, or are you or your spouse buying any? Yes ___ No___ What is the approximately value? $______

How much did you pay for it? $______When? ______Is it paid for? Yes ______No ______

If not, how much do you or your spouse owe? $______

C.Checking account(s)?Yes _____ No ______Balance $______

Savings accounts(s)?Yes _____ No ______Balance $______

Stocks or bonds?Yes _____ No ______Value $______

Bank(s)______

Wages due but not yet received$______

Money owed to me or my spouse$______

Guns, boats, sporting equipment,

Trailer, camper, or tools$______

Stereo or TV$______

Furniture & appliance$______

Other personal property$______Specify______

______

IV. OBLIGATION/DEBTS:

Monthly Expenses:

Home:Own ______Rent ______Monthly payment$______

Heat/Lights$______Phone$______

Clothing$______School$______

Food$______Insurance$______

Transportation$______Child Support$______

Miscellaneous Expenses: (What for/monthly payment)

I further declare that I am the person named above, that I have read the foregoing questions and information and know the same to be true of my own knowledge, AND THAT IF ANY PART OF THE ABOVE IS MADE FALSELY I AM SUBJECT TO PROSECUTION FOR PERJURY.

______

Signature

SUBSCRIBED AND SWORN to before me this ______day of ______, ______.

______

Notary Public for the State of Montana

Residing at ______

My Commission Expires ______

ORDER

The Court having reviewed the above Indigency Questionnaire, ______finds

_____ does not find good cause for waiving:

______participant fees in the amount of $______; or

______completion of the Prime for Life Program under the DUI Court

prior to: entering into _____ Phase _____; or ______graduating from treatment Court due to indigencywhich precludes the participant from paying the participation fee and/or the fee for the Prime for Life Program. THIS WAIVER DOES NOT WAIVE THE PARTICIPANT’S MANDATORY STATUTORY OBLIGATION TO COMPLETE THE PRIME FOR LIFE PROGRAM PURSUANT TO CONVICTION UNDER ANY IMPAIRED DRIVING PENALTY STATUTE OUT OF THE REFERRING COURT.

Dated: ______

Hon. Audrey Barger

Hill County Treatment Court Judge