UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI ) ), Plaintiff, ) ) vs. ) Case No. ) ), Defendant(s). ) ) MOTION TO PROCEED IN FORMA PAUPERIS AND AFFIDAVIT IN SUPPORT -- PRISONER CASES I, declare (1) that I am the in this case; (2) that because of my poverty, I am unable to pay the $150.00 filing fee; and (3) that I believe I am entitled to relief. The nature of my action and the issues are briefly stated as follows: In further support of this application, I answer the following questions: 1. Have you ever before brought an action or appeal in a federal court while you were incarcerated or detained? Yes No If so, how many times? Were any of the actions or appeals dismissed because they were frivolous, malicious, or failed to state a claim upon which relief may be granted? Yes No If so, how many of them? 2. Place of confinement of plaintiff or petitioner: 3. Crime(s) for which you have been convicted, date and sentence on each: >>>> 24. Are you presently employed? Yes No a. If the answer is "yes," state the amount of your salary or wages per month, and give the name and address of your employer. b. If the answer is "no," state the date of last employment and the amount of the salary and wages per month which you received. 5. Have you received, within the past twelve (12) months, money from any of the following sources? Yes No Business, profession or form of self-employment? Rent payments, interest or dividends? Pensions, annuities or life insurance payments? Gifts or inheritances? Any other sources? If the answer to any of the above is "yes," describe the source and amount of money received from each during the past twelve (12) months. 6. Do you own any cash, or do you have money in a checking or savings account? Include any funds in prison accounts during the last six (6) months. Yes No If the answer is "yes," state the total amount of cash owned, and the average monthly balance in all checking, savings or prison account during the last six (6) months. 2 >>>> 37. Do you own real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes No If the answer is "yes," describe the property and state its approximate value. 8. List the persons who are dependent upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support. I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT PROVIDING FALSE INFORMATION MAY SUBJECT ME TO CRIMINAL PROSECUTION, IMPOSITION OF A FINE, OR OTHER SANCTION THAT MAY ADVERSELY AFFECT MY ABILITY TO PURSUE THIS CASE OR OTHER CASES. I HAVE REVIEWED MY ANSWERS TO INSURE THEIR ACCURACY. Executed (signed) this day of , 20 . (Signature of plaintiff) NOTE: THIS AFFIDAVIT MUST BE ACCOMPANIED BY A CERTIFIED COPY OF YOUR PRISON ACCOUNT STATEMENT SHOWING THE AMOUNT OF MONEY ON DEPOSIT DURING THE LAST SIX (6) MONTHS. A "CERTIFIED COPY" OF YOUR ACCOUNT STATEMENT IS ONE THAT HAS BEEN CERTIFIED BY AN AUTHORIZED PRISON OFFICER THAT IT IS A TRUE AND CORRECT COPY. FAILURE TO SUBMIT A CERTIFIED ACCOUNT STATEMENT WILL RESULT IN THE RETURN OF YOUR COMPLAINT OR PETITION. 3