IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF VIRGINIA Richmond Division ___________________________________, Plaintiff v. Civil Action No. _______________ ____________________________________, Defendant(s) MOTION TO PROCEED IN FORMA PAUPERIS AND FINANCIAL AFFIDAVIT I, ____________________________________, say that I am the plaintiff in the aboveentitled case, that I move to proceed without being required to prepay fees, costs or give security therefor, and that in support of this motion I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therefor; and that I believe I am entitled to relief. I further state that the responses which I have made to questions and instructions below are true. EMPLOYMENT Are you employed? _____Yes _____No _____Self-Employed IF YES, How much do you earn per month? __________________________________________ Name & Address of employer: ______________________________________________ IF NO, give month and year of last employment: ______________________________________ How much did you earn per month? __________________________________________ IF MARRIED, is your spouse employed? _____Yes _____No IF YES, how much does your spouse earn per month? __________________________________ IF A MINOR, what is your parents’ approximate monthly income? ________________________ OTHER INCOME Have you received within the past 12 months any income from a business, profession or other form of self-employment, or in rent payments, interest dividends, retirement or annuity payments, gifts or inheritance or other sources? _____Yes _____No IF YES, give the amount received and identify the source(s): $______________________ Received from Source(s)_________________________________ $______________________ Received from Source(s)_________________________________ CASH Have you any cash on hand or money in savings or checking accounts? _____Yes _____ No American LegalNet, Inc. www.FormsWorkFlow.com Total Amount: Checking $__________ Savings $__________ Other $__________ PROPERTY Do you own any real estate, stocks, bonds, notes, automobiles, boats, or other valuable property (excluding ordinary furnishings and clothing)? _____Yes _____No IF YES, give value and describe it: Value Description $______________________ $______________________ ________________________________________________ ________________________________________________ MARITAL STATUS _____ Single _____Married _____Widowed _____Separated or Divorced DEPENDENTS Total Number of Dependents: _____ List persons you actually support, your relationship to them and how much you contribute toward their support: _____________________________________ ______________________________________ _____________________________________ _______________________________________ DEBTS & MONTHLY BILLS List all creditors, including banks, loan companies, charge accounts, etc.: Creditors ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Total Debt $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ Monthly Payment $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ I declare under penalty of perjury that the foregoing is true and correct. Executed on ______________________ (Date) __________________________________________ (Signature) Address: ________________________________________________ _______________________________________________ ________________________________________________ Phone Number: ________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com