UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA CASE NUMBER PLAINTIFF/PETITIONER, v. DEFENDANT(S). REQUEST TO PROCEED IN FORMA PAUPERIS WITH DECLARATION IN SUPPORT , declare under penalty of perjury, that the foregoing is true and I, correct; that I am the petitioner/plaintiff in the above entitled case; that in support of my motion to proceed without being required to prepay fees, costs or give security therefore, I state that because of my poverty I am unable to pay the costs of said proceedings or to give security therefore and that I am entitled to redress. I further declare under penalty of perjury that the responses which I have made to the questions and instructions below are true, correct and complete. 1. Are you presently employed? GYes GNo 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. 2. Have you received, within the past twelve months, any money from any of the following sources? a. Business, profession or form of self-employment? b. Rent payments, interest or dividends? c. Pensions, annuities or life insurance payments? d. Gifts or inheritances? e. Any other income (other than listed above)? f. Loans? GYes GYes GYes GYes GYes GYes GNo GNo GNo GNo GNo GNo If the answer to any of the above is yes, describe such source of money and state the amount received from each source during the past twelve (12) months: REQUEST TO PROCEED IN FORMA PAUPERIS WITH DECLARATION IN SUPPORT CV-60 (04/06) Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com 3. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison accounts, if applicable.) GYes GNo If the answer is yes, identify each account and separately state the amount of money held in each account for each of the six (6) months prior to the date of this declaration. 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? GYes GNo If the answer is yes, describe the property and state its approximate value: 5. In what year did you last file an Income Tax return? Approximately how much income did your last tax return reflect? 6. List the persons who are dependent upon your for support, state your relationship to those persons, and indicate how much you contribute toward their support: I understand that a false statement or answer to any question in this declaration will subject me to penalties for perjury. I further understand that perjury is punishable by a term of imprisonment of up to five (5) years and/or a fine of $250,000 (18 U.S.C. Sections 1621, 3571). State County (or City) I, foregoins is true and correct. , declare under penalty of perjury that the Date Plaintiff/Petitioner (Signature) REQUEST TO PROCEED IN FORMA PAUPERIS WITH DECLARATION IN SUPPORT CV-60 (04/06) Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com