IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ALABAMA IN FORMA PAUPERIS AFFIDAVIT Declaring that the information I have given below is true and correct, I apply to this court for: ( ) security. authority to commence an action with prepayment of fees, costs or I. PERSONAL AND FINANCIAL DATA A. Your full name and present mailing address: Telephone (if any): B. Are you presently employed? Yes No If the answer is "yes," give the name and address of your employer and the amount of your usual weekly salary or wages. Weekly earning: $ If you are not presently employed, give name and address of your last employer, when you last worked, and the amount of weekly salary or wages you were receiving. Date last worked: Weekly earnings: Approximately how much money have you received in the past twelve months: as wages, salary, commissions, or earned income of any kind? $ as interest, dividends, rents, or investment income of any kind? $ American LegalNet, Inc. www.USCourtForms.com as gifts or inheritance? $ from social security, unemployment compensation, or any form of state or federal welfare payments or benefits? $ from pensions, annuities, workmen's compensation, disability or other insurance policies $ from all other sources? $ C. How much money do you own or have in any checking or savings accounts? $ D. Do you own any real estate, stocks, bonds, notes, automobiles, boats, or other valuable property (excluding ordinary household items and clothing)? $ If the answer is "yes," describe the property and state its approximate value: E. How much money do you owe to others? $_____________________ As to each debt of over $100.00, state the name of the creditor and the approximate amount owed: F. List the persons who are dependent upon you for support, stating your relationship to them and how much you contribute each year toward their support. G. Are there any other persons regularly residing in your household who are over the age of 18 and who are presently employed? Yes No American LegalNet, Inc. www.USCourtForms.com If the answer is "yes," give the following information for each such person: Name: Relationship: Employer: Weekly earnings:$ Name: Relationship: Employer: Weekly earnings:$ H. Any other information which you believe supports your claim that you cannot financially afford to employ an attorney or to make payment of court fees, costs, or security. III. ATTESTATION AND SIGNATURE Under penalty of perjury, I declare that the information given on the preceding pages is true and correct. Dated: SIGNATURE WITNESS: American LegalNet, Inc. www.USCourtForms.com