1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 If the answer is "no," state the date of last employment and the amount of the gross and net salary 1. I, , declare, under penalty of perjury that I am the plaintiff Defendant. vs. Plaintiff, ) ) ) ) CASE NO. ) ) APPLICATION TO PROCEED ) IN FORMA PAUPERIS ) ) ) ) UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA in the above entitled case and that the information I offer throughout this application is true and correct. I offer this application in support of my request to proceed without being required to prepay the full amount of fees, costs or give security. I state that because of my poverty I am unable to pay the costs of this action or give security, and that I believe that I am entitled to relief. In support of this application, I provide the following information: Are you presently employed? Yes No If your answer is "yes," state both your gross and net salary or wages per month, and give the name and address of your employer: Gross: Employer: Net: -1- American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 and wages per month which you received. 2. Have you received, within the past twelve (12) months, any money from any of the following sources: a. Business, Profession or self employment? b. Income from stocks, bonds, or royalties? c. d. Rent payments? Pensions, annuities, or life insurance payments? e. Federal or State welfare payments, Social Security or other government source? If the answer is "yes" to any of the above, describe each source of money and state the amount received from each. Yes No Yes Yes No No Yes No Yes No 3. Are you married? Yes No Spouse's Full Name: Spouse's Place of Employment: Spouse's Monthly Salary, Wages or Income: Gross $ 4. a. b. Net $ List amount you contribute to your spouse's support:$ List the persons other than your spouse who are dependent upon you for support and indicate how much you contribute toward their support. (NOTE: For minor -2- American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 9. 8. 5. children, list only their initials and ages. DO NOT INCLUDE THEIR NAMES.) Do you own or are you buying a home? Yes No Estimated Market Value: $ 6. Make Is it financed? Yes Monthly Payment: $ 7. Do you have a bank account? Yes No Do you own an automobile? Year Amount of Mortgage: $ Yes Model If so, Total due: $ No No (Do not include account numbers.) Name(s) and address(es) of bank: Present balance(s): $ Do you own any cash? Yes No Amount: $ Do you have any other assets? (If "yes," provide a description of each asset and its estimated market value.) Yes No What are your monthly expenses? Utilities: Clothing: Rent: $ Food: $ Charge Accounts: Name of Account $ $ $ Monthly Payment $ $ $ Total Owed on This Account Do you have any other debts? (List current obligations, indicating amounts and to whom they are payable. Do not include account numbers.) -3- American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 DATE SIGNATURE OF APPLICANT I declare under the penalty of perjury that the foregoing is true and correct and understand that a false statement herein may result in the dismissal of my claims. 10. Does the complaint which you are seeking to file raise claims that have been presented in Yes No other lawsuits? Please list the case name(s) and number(s) of the prior lawsuit(s), and the name of the court in which they were filed. -4- American LegalNet, Inc. www.FormsWorkFlow.com