Rev. 6-2-17 UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS PURSUANT TO 28 U.S.C. 2471915 , Plaintiff(s), v. Case No. , Defendant(s). I request leave to commence this civil action without prepayment of fees, costs, or security therefor pursuant to 28 U.S.C.247 1915. In support of my request, I submit the attached financial affidavit and state that: (1)I am unable to pay such fees, costs, or give security therefor.(2)I am entitled to commence this action against the defendant(s).(3)I request that the court direct the United States Marshal's Service to serveprocess. Original Signature Name (print or type) Street Address City State Zip Code ( ) Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com