Rev 6-2-17 UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT FINANCIAL AFFIDAVIT IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS PURSUANT TO 28 U.S.C. 2471915 , Plaintiff(s), v. Case No. ---------------------------- , Defendant(s). I declare that: (1)I am unable to pay such fees, costs, or give security therefor.(2)I am entitled to commence this action against the defendant(s). I further state that the responses I have made to the questions below relating to my ability to pay the cost of prosecuting this action and other matters are true. MARITAL STATUS Single Married Separated Divorced If separated or divorced, are you paying any support or any form of maintenance? Yes No Dependents: Spouse Children # Others # and relationship Please provide the names and ages of your children. If a child is a minor, please identify the child by initials only. Name Age Name Age Name Age RESIDENCE Street Address: City: State: American LegalNet, Inc. www.FormsWorkFlow.com Rev. 6-2-17 Zip Code: Telephone: EDUCATION Please circle the highest level of formal education you have received: Grammar School K 1 2 3 4 5 6 7 8 High School 9 10 11 12 College 1 2 3 4 Post-Graduate 1 2 3 4 EMPLOYMENT If employed at present, complete the following: Name of employer: Address of employer: How long employed by present employer: Gross Income before taxes or other deductions: Monthly Weekly If self-employed state gross weekly wages before taxes and deductions: What is the nature of your employment? If unemployed at present, complete the following: I have been unemployed since the day of , The name of my last employer: Address: Telephone #: ( ) Last salary or wages received (gross amount before taxes and deductions): If spouse is employed, please complete the following: Name of employer: How long employed: Gross Income before taxes and deductions: Monthly Weekly What is the nature of spouse's employment? If on welfare or receiving unemployment benefits complete the following: I have been on welfare or receiving unemployment benefits since: I am receiving $ monthly weekly for myself and family of . If receiving social security, disability or workers' compensation benefits complete the following: I have been receiving social security, disability or workers' compensation benefits since: . I am receiving $ monthly weekly. FINANCIAL STATUS Owner of real property? Yes No American LegalNet, Inc. www.FormsWorkFlow.com Rev 6-2-17 If yes, description: Address: In whose name? Estimated value: Amount owed: Owed to: Total: Monthly payment Owed to: Total: Monthly payment Annual income from property: Other property: Automobile: Make Model Year Registered owner(s) name(s): Present value of automobile: Owed to: Amount owed: Cash or Securities on hand: Cash in banks and savings and loan associations: Names and addresses of banks and associations: Stocks or bonds owned: Indicate current value and name of company and number of shares of stock or identify bonds : OBLIGATIONS: Monthly rental on house or apartment: $ Monthly mortgage payment on house: $ Gas bill per month: $ Electric bill per month: $ Phone bill per month: $ Car payments per month: $ Car insurance payments per month: $ Other types of insurance payments per month $ Monthly payments to retail merchants: $ Please list: $ Please list: $ Monthly payments on any other outstanding loans or debts: $ Please list: $ Please list:$ American LegalNet, Inc. www.FormsWorkFlow.com Rev. 6-2-17 Any money owed to doctors, hospitals, lawyers Please list: $ Please list:$ Monthly payment for maintenance or child support under separation or dissolution agreement: $ Estimated monthly expenditure on food: $ Estimated monthly expenditure on clothing: $ Total amount of monthly obligations: $ Other information pertinent to financial status: (Include stocks, bonds, savings bonds, interests in trusts either owned or jointly owned): PREVIOUS LITIGATION: If you have ever filed a case in this district, provide the following information for each case you have filed. If you need additional space, please continue on a separate sheet. Case Number Case Caption Disposition of Case 1. 2. 3. 4. Date: Original Signature of Affiant DECLARATION UNDER PENALTY OF PERJURY I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct to the best of my knowledge and belief. Date: Original Signature of Affiant American LegalNet, Inc. www.FormsWorkFlow.com