UNITED STATES BANKRUPTCY COURTDISTRICT OF CONNECTICUTAPPLICATION FOR APPOINTMENT OF ATTORNEY ATTORNEYS ARE APPOINTED UNDER THIS COURT222S PRO BONO PROGRAM TO REPRESENT INDIVIDUAL DEBTORS IN CHAPTER 7 AND CHAPTER 13 CASES.IF YOUR APPLICATION FOR THE APPOINTMENT OF AN ATTORNEY ISGRANTED AND IF THE ATTORNEY ASSIGNED TO REPRESENT YOUDETERMINES THAT IT IS IN YOUR BEST INTEREST TO FILE A PETITIONUNDER CHAPTER 13 AND A CHAPTER 13 PLAN IS FILED, YOUR ATTORNEYMAY REQUEST THE COURT TO ALLOW A REASONABLE FEE ANDREIMBURSEMENT FOR ACTUAL, NECESSARY EXPENSES TO BE PAID OUT OFTHAT PLAN.INSTRUCTIONS 1. If this is a joint application (filed by a husband and wife), each must provide all requestedinformation. Please indicate by (H) and (W) if an answer to a particular question only applies tothe husband or to the wife.2. Attach additional sheets of paper if necessary.3. Return this motion to:Clerk, United States Bankruptcy Court 915 Lafayette Boulevard Bridgeport, CT 06604 I. Personal/Financial DataA. State your full name, present mailing address, and a telephone number:B. Do you presently have a pending bankruptcy case? If the answer is yes, state the location of the court and the bankruptcy case number C. Are you presently employed? If the answer is yes, state:(a) the kind of job(s) you have: American LegalNet, Inc. www.FormsWorkFlow.com (b) the name, address, and telephone number of your employer:(c) the amount of your usual weekly wages or salary:gross $ ; take home pay $D. Are you self employed? If the answer is yes, state:(a) the kind of work you do: (b) the name, address, and telephone number of your business: (c) the amount of your ususal weekly income:gross $; take home pay $ E. If you are not presently employed or self employed state:(a) the name and address of your last employer: (b) when you last worked: (c) the amount of your last weekly wages, salary, or income:gross $ ; take home pay $ F. Approximately how much money have you received in the past twelve months from:(a) salary, wages, commissions, and other income: $(b) interest, rent, and investments of any kind: $ (c) gifts, inheritance, and the sale of any property of any kind: (attach itemized list) $ G. Do you have any money in any checking, savings, credit union, or similar accounts?If the answer is yes, state:(a) the name and address of the depository (bank, credit union, etc):(b) your account number(s): (c) the amount of money in each account: $ H. Is any person, company, or governmental agency holding any money or property which youhave a right to demand or receive? If the answer is yes, state:(a) the name and address of the person, company, or agency: (b) the basis for your claim: American LegalNet, Inc. www.FormsWorkFlow.com (c) the amount of money and/or a description of the property: J. Do you own any real estate or other property, excluding household items and clothing: If the answer is yes, describe the property: and state:(a) its location: (b) the approximate present value of each such item of property after deducting the current balance of all mortgages and other liens on that property: K. List each person who depends upon you for support and state your relationship to that person:L. Are there any persons regularly residing in your household who are over the age of eighteenand regularly employed? If the answer is yes, state as to each person:(a) name: (b) relationship to you: (c) name and address of employer: M. Itemize all household and living expense per month:(a) rent/mortgage payments:$ (b) food:$ (c) utilities:$ (d) transportation:$ (e) insurance:$ (f) other: $ (g) $ (h) $ (i) $ (j) $ Total $ N. Include any other information which you believe supports your claim that you cannot affordto employ an attorney: American LegalNet, Inc. www.FormsWorkFlow.com II. Efforts to Obtain an AttorneyA. Have you spoken with any attorney about handling your bankruptcy case or any matter arisingout of or relating to your bankruptcy case? If the answer is yes, state:(a) Each attorney222s name and address: (b) The approximate date you contacted each attorney: (c) How (by telephone, in person, etc.): (d) Reason why attorney was not employed: B. Do you need an attorney who speaks a language other than English? If the answer is yes, state the language you speak: American LegalNet, Inc. www.FormsWorkFlow.com I declare under the penalties of perjury that my answers to the foregoing questions are true to thebest of my knowledge.I understand that if I am assigned an attorney and my attorney learns, either from me orelsewhere, that I can afford an attorney, my attorney may give that information to the Court. SeeBankruptcy Court Local Rule 1(b) and District Court Local Rule 29(b)(4) and (g).I hereby waive my privileges of attorney/client confidentiality to the extent necessary for myappointed attorney to make an application to be relieved from appointment as provided inDistrict Court Local Rule 29(c) and (d).Dated:Signature of ApplicantSignature of ApplicantDo not write below this lineORDERThe Application for Appointment of Attorney is GRANTED/DENIED AND IT IS ORDEREDTHATis appointed to represent the applicant. American LegalNet, Inc. www.FormsWorkFlow.com