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EA L TH OF KE lex et justitia E RT C U Commonwealth of Kentucky Court of Justice www.courts.ky.gov Case No. UCKY COMM NW NT O Doc. Code: AOII CO AOC-495.8 Rev. 7-15 Page 1 of 2 OF JUS TI FINANCIAL STATEMENT, AFFIDAVIT OF INDIGENCY, AND REQUEST FOR REDUCED IGNITION INTERLOCK DEVICE COSTS KRS 403.761(9)(b); KRS 189A.420 Court County Division COMMONWEALTH OF KENTUCKY PLAINTIFF.

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