STATE OF NEW MEXICO                )
COUNTY OF _____________________    )

    ___________________________, attorney at law, upon oath or affirmation states as follows:
    1.    I am counsel for the petitioner in regard to the petition for dissolution of marriage that has been filed in connection with petitioner's affidavit in forma pauperis;
    2.    I have not received any fee from the petitioner, nor do I expect that petitioner will be able to pay any fee to me based upon the representations made in petitioner's affidavit. I am satisfied as to the truth of the allegations contained in the petitioner's affidavit.
    3.    I represent to the court that in the event that any money is paid to me by the petitioner or on petitioner's account for my services rendered on petitioner's behalf, I shall first deduct the costs which have been waived on behalf of the petitioner and pay them to the clerk of the this court.
    4.    I am satisfied that my client has truthfully represented to the court my client's present financial status, and that my client is unable to afford the costs of filing this cause of action and should be awarded free process by the court.

                __________________________________
                Attorney's name

                __________________________________
                Attorney's address

                __________________________________
                (Attorney's telephone number

SUBSCRIBED AND SWORN TO before me this _____ day of __________________, _______, by ___________________.

__________________________
Notary Public

My Commission Expires:
__________________________

[Approved, effective October 2, 2000.]