IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF ALABAMA Plaintiff(s)/Petitioner(s) vs. CIVIL ACTION NO. (To be supplied by Clerk of Court) Defendant(s)/Respondent(s) MOTION TO PROCEED WITHOUT PREPAYMENT OF FEES , a United States citizen, make this Motion to I, Proceed Without Prepayment of Fees pursuant to Title 28 U.S.C. § 1915 in order to proceed in forma pauperis in this action. I am unable to make prepayment of fees or to give security therefor, and it is my belief that I am entitled to redress. I have not divested myself of any property, monies or any items of value for the purpose of avoiding payment of said fees. I. BRIEF STATEMENT AS TO THE NATURE OF THE ACTION: II. RESIDENCE: Your address: (City) (Street) (State) (Zip Code) III. MARITAL STATUS: 1. Single _______ Married _______ 2. If married, spouse's full name: IV. DEPENDENTS: 1. Number: _______ 2. Relationship to dependent(s): 3. How much money do you contribute toward your dependents' support on a monthly basis? $ _______________ Separated _______ Divorced _______ Revised 4/10/06 American LegalNet, Inc. www.FormsWorkflow.com V. EMPLOYMENT: 1. Name of employer: a. Address of employer: (Street) (City) (State) (Zip Code) b. How long have you been employed by present employer? Years: _______ Months _______ c. Income: Monthly $_______________ or Weekly $_______________ d. What is your job title? 2. If unemployed, date of last employment: Amount of salary and wages received per month in last employment: $ ________ 3. Is spouse employed? __________ If so, name of employer: a. Income: Monthly $_______________ or Weekly $_______________ b. What is spouse's job title? 4. Are you and/or your spouse receiving welfare aid? If so, amount: Monthly $_______________ or Weekly $_______________ VI. FINANCIAL STATUS 1. Owner of real property (excluding ordinary household furnishings and clothing): a. Description: b. Full Address: c. In whose name: d. Estimated value - - - - - - - - - - - - - - - - - - - - - - - - - - $ e. Total amount owed - - - - - - - - - - - - - - - - - - - - - - - - $ $ Owed to: $ f. Annual income from property - - - - - - - - - - - - - - - - - - $ 2. Other assets/property, such as automobiles, boats, motor homes, court judgments, etc. (If more than two, list information on back): Asset (2) a. Asset (1) Make & Model: In whose name registered? Present Value of Asset: Amount owed: Owed to: b. Total cash in banks, savings and loan associations, prisoner accounts, 2 American LegalNet, Inc. www.FormsWorkflow.com financial institutions, other repositories, or anywhere else - $ c. List monies received by you during the last twelve (12) months, or held for you by banks, savings and loan associations, prisoner accounts, other financial institutions, or other sources as indicated below: Business, profession or other forms of self-employment - $ Rent payments, interest or dividends - - - - - - - - - - - - - - $ Pensions, annuities or life insurance payments - - - - - - - $ Gifts or inheritances - - - - - - - - - - - - - - - - - - - - - - - - - - $ Stocks, bonds or notes - - - - - - - - - - - - - - - - - - - - - - - - $ Tax refunds, Veteran benefits or social security benefits $ Any other sources - - - - - - - - - - - - - - - - - - - - - - - - - - - $ 3. Obligations: a. Monthly rental on house or apartment - - - - - - - - - - - b. Monthly mortgage payments on house - - - - - - - - - - - - $ $ 4. Other information pertinent to your financial debts and obligations: (Creditor) (Total debt) (Monthly payment) (Creditor) (Total debt) (Monthly payment) (Creditor) (Total debt) (Monthly payment) 5. If you have indicated that you have minimal or no assets or income, please explain how you provide for your basic living needs such as food, clothing and shelter. (e.g. food stamps, family assistance or charitable contributions.) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Other (Explain): _________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkflow.com VII. ALL PLAINTIFFS/PETITIONERS MUST READ AND SIGN: I UNDERSTAND that any false statement(s) of a material fact contained herein may serve as the basis of prosecution and conviction for perjury or making false statements. FURTHER, I CERTIFY that all questions contained herein have been answered and are true and correct to the best of my knowledge and belief. DATE SIGNATURE OF PLAINTIFF/PETITIONER ADDRESS 4 American LegalNet, Inc. www.FormsWorkflow.com VIII. FOR PRISONER PLAINTIFFS/PETITIONERS ONLY: A financial statement containing all transactions in your prisoner account for the six (6) months immediately preceding the filing of the Complaint must accompany this Motion. The financial statement must be in the form of a computer printout or bank ledger card prepared by the institution; a notarized financial statement that you prepare; or a financial statement prepared by an authorized officer of the institution. Failure to provide this financial statement information may result in the dismissal of this action. The requirement to submit the financial statement addressed above does not negate your responsibility to ensure that the Certificate found below is also properly executed and filed. I hereby authorize the agency having custody of me to collect from my prison account and forward to the Clerk of the United States District Court payments in accordance with 28 U.S.C. § 1915(b)(2). I understand that even if I am allowed to proceed in forma pauperis or pay a partial filing fee and even if my case is later dismissed for any reason, I am obligated to pay to the Clerk of the Court the full amount of the filing fee ($350.00 for a civil action, $5.00 for a habeas corpus petition, or $455.00 for an appeal). ____________________ DATE _______________________________________________ SIGNATURE OF PLAINTIFF/PETITIONER CERTIFICATE (To be completed by the institution of incarceration) I certify that the applicant named herein has the sum of $__________ on account to his/her credit at _________________________ (name of institution). I further certify that during the past six months the applicant's average monthly balance was $__________. I further certify that during the past six months the average of monthly deposits to the applicant's account was $__________. (Please attach a certified copy of the applicant's account statement showing transactions for the past six months.) ____________________ DATE _______________________________________________ SIGNATURE OF AUTHORIZED OFFICER 5 American LegalNet, Inc. www.FormsWorkflow.com