SUPERIOR COURT OF THE DISTRICT OF COLUMBIA FAMILY COURT ________________________________________ PRINT PETITIONER’S/PLAINTIFF’S NAME PETITIONER/PLAINTIFF, v. _________________________________ Case No. ____________________ PRINT RESPONDENT’S/DEFENDANT’S NAME RESPONDENT/DEFENDANT. REQUEST TO PROCEED WITHOUT PRE-PAYMENT OF COSTS (In Forma Pauperis) I, ________________________________, am the PRINT YOUR NAME PLAINTIFF/PETITIONER DEFENDANT/RESPONDENT in this case. I respectfully ask this Court to allow me to pursue this case without pre-paying fees or costs and without giving security for them. In support of this request, I state the following: 1. I am not able to pay the costs of this case or to give security for it without substantial hardship to myself or to my family. 2. The issues I want to present to the Court are set out in the attached document(s): [CHECK ALL THAT APPLY] Complaint Counterclaim Petition Motion Subpoena DC Bar Pro Bono Program (revised 03.05) Request to Proceed Without Pre-Payment of Costs Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com 3. I state the following about my income: [CHECK ALL THAT APPLY] I receive the following public benefits, and the law presumes that I am eligible to proceed without pre-payment of costs: Temporary Assistance to Needy Families (TANF) Program on Work, Employment, and Responsibility (POWER) General Assistance for Children (GAC) Supplemental Security Income or Social Security Disability (SSI or SSDI) Interim Disability Assistance (IDA) Food Stamps I am employed and I state the following about my employment: I earn $______________________ per month. My employer is _________________________________________________. My employer’s address is _________________________________________. I am not employed and I state the following about the last time I was employed: I have never been employed. I was last employed on __________ and earned $______________ per month. DATE In the past 12 months, I have received the following other income: I have received $____________ from ________________________________. I have received $____________ from ________________________________. 4. I state the following about my property: I do not have any cash, savings or checking accounts. I do not own any automobiles, real estate, stocks, bonds, or other valuable property. I have $_______________ in cash, including money in savings or checking accounts. I own the following vehicles, real estate, stock, bonds, or other valuable property: ________________________________________________________________________ ________________________________________________________________________ [LIST THE PROPERTY AND AMOUNT OF MONEY IT IS WORTH] DC Bar Pro Bono Program (revised 03.05) Request to Proceed Without Pre-Payment of Costs Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com 5. I state the following about my debt: I do not owe any money. I owe the following amounts of money: $ AMOUNT OWED OWED TO $ AMOUNT PAID EACH MONTH ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 6. The following persons are dependent upon me for support: NAME RELATIONSHIP ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ I RESPECTFULLY REQUEST that the Court grant my Request to Proceed without PrePayment of Costs. Respectfully Submitted, ____________________________________ SIGN YOUR NAME ___________________________________________ STREET ADDRESS ___________________________________________ CITY, STATE AND ZIP CODE ___________________________________________ TELEPHONE NUMBER SUBSTITUTE ADDRESS: CHECK BOX IF YOU HAVE WRITTEN SOMEONE ELSE’S ADDRESS BECAUSE YOU FEAR HARASSMENT OR HARM. DC Bar Pro Bono Program (revised 03.05) Request to Proceed Without Pre-Payment of Costs Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com I, _________________________________, solemnly swear or affirm under criminal penalties for the making of a false statement that I have read the foregoing Request for Permission to Proceed Without Pre-Payment of Costs and Supporting Affidavit and that the factual statements made in it are true to the best of my personal knowledge, information and belief. ___________________________________ ______________________________ SIGN YOUR NAME DATE ___________________________________ PRINT YOUR NAME POINTS AND AUTHORITIES IN SUPPORT OF REQUEST TO PROCEED WITHOUT PRE-PAYMENT OF COSTS In support of my Request to Proceed Without Pre-Payment of Costs, I refer to: 1. Super. Ct. Dom. Rel. R. 7(b)(1)(A) and 54(f). 2. D.C. Code §§ 15-712, 13-340(a), and 16-918(a). DC Bar Pro Bono Program (revised 03.05) Request to Proceed Without Pre-Payment of Costs Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com SUPERIOR COURT OF THE DISTRICT OF COLUMBIA FAMILY COURT ________________________________________ PRINT PETITIONER’S/PLAINTIFF’S NAME PETITIONER/PLAINTIFF, v. Case No. ____________________ _________________________________ PRINT RESPONDENT’S/DEFENDANT’S NAME RESPONDENT/DEFENDANT. ORDER Upon consideration of PLAINTIFF’S DEFENDANT’S Request for Permission to Proceed Without Pre-Payment of Costs, any and all supporting argument and documentation provided, and the record herein, it is this _____________ day of _____________________, 20_______ hereby ORDERED that ________ The request is GRANTED. ________ The request is DENIED. SO ORDERED. ____________________________ ______________________________ DATE JUDGE’S SIGNATURE DC Bar Pro Bono Program (revised 03.05) Request to Proceed Without Pre-Payment of Costs Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com