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 Name: Address: Telephone Phone: Email: UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF CALIFORNIA Case No.: ___________________ , Plaintiff(s), v. REQUEST FOR APPOINTMENT OF COUNSEL , Defendant(s). I, ______________________________, move for the appointment of counsel. To support this motion, I declare under penalty of perjury that (check one): I have been granted, or have applied for, permission to proceed in forma pauperis. I have attached an affidavit demonstrating my inability to pay the cost of an attorney. I have made the following diligent efforts to obtain legal counsel but have been unsuccessful because of my poverty (describe below, include information for each attorney you contacted): 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 Attorney: When: Where: How (by telephone, in person, etc.): Why attorney was not employed to handle your claim: Attorney: When: Where: How (by telephone, in person, etc.): Why attorney was not employed to handle your claim: Attorney: When: Where: How (by telephone, in person, etc.): Why attorney was not employed to handle your claim: 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 I need appointed counsel to assist me because (describe below): Date Signature Printed Name 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 7. 6. 5. 3. 4. 1. 2. AFFIFAVIT IN SUPPORT OF REQUEST FOR COUNSEL (DO NOT COMPLETE THIS PART IF YOU HAVE ALREADY SUPPLIED THIS INFORMATION IN THE APPLICATION TO PROCEED IN FORMA PAUPERIS.) Full Name: Address: Marital Status: Single Married Yes Separated No Divorced Widowed Are you presently employed? If the answer is "Yes", give your occupation, the name and address of your employer and the gross and net amount of your salary. If you are not presently employed, state the date of your last employment, the name and address of your employer and your salary. If you are married and if our spouse is employed, state his/her name, occupation, employer, address of employer and salary. Approximately how much money have you received in the past twelve month from the following sources: as wages, salary, commissions or earned income of any kind? 4 ___________________ 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. as workman's compensation or disability insurance? as rent payments, interest, dividends? as pension, annuities or life insurance payments? from social security, unemployment compensation or welfare payments? as gifts or inheritance? from other sources? How much money do you own or have in any checking or savings account? Do you own or have any interest in any real estate, automobiles or other vehicles, boats, stocks, bond, notes, or any other valuable property (excluding ordinary household furnishings and clothing)? Yes No If "Yes", give a description of the property and its estimated value. 5 ___________________ 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 10. Is anyone dependent on you for support? Yes No If "Yes", give names, ages, relationship to you, and the amount you contribute toward their support. 11. List any debts you have and the amount owed. Creditor Amount Owed 12. List your monthly living expenses. Under penalty of perjury, I declare that the information given in this motion is true and correct. Date Signature Printed Name 6 ___________________ American LegalNet, Inc. www.FormsWorkFlow.com