UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT Name of Plaintiff/Petitioner v. Case No. Name of Defendant/Respondent MOTION FOR APPOINTMENT OF COUNSEL PERSONAL/FINANCIAL DATA 1. Your full name: Your present mailing address: Telephone number: 2. 3. ( ) NO Are you presently employed? YES If your answer to #2 is YES, please provide the name and address of your employer and the amount of your usual weekly earnings. Weekly earnings: 4. If you are not presently employed, please provide the name and address of your last Rev. 2/3/05 American LegalNet, Inc. www.FormsWorkFlow.com employer, the date (approximate) that you last worked, and the amount of weekly earnings you were receiving. Date last worked: Weekly earnings: 5. Approximately how much money have you received in the past twelve months in the form of: a) salary, wages, commissions, or earned income of any kind? b) interest, dividends, rents or investments of any kind? c) gifts or inheritances of any kind? 6. How much money do you have in any checking or savings account(s)? Checking: Savings: Prison account: 7. Do you own any real estate, stocks, bonds, notes, automobiles, boats, or other valuable property (excluding household items and clothing)? YES NO If YES, describe the property and state the approximate value: 8. How much money do you owe others? For each debt, state the name of the creditor and the amount owed: CREDITOR AMOUNT OWED 2 Rev. 2/3/05 American LegalNet, Inc. www.FormsWorkFlow.com 9. List the persons who depend upon you for support, and state your relationship to them. If any person is a minor child, identify that person by initials only. 10. Are there any persons regularly residing in your household who are over the age of 18 and who are presently employed? YES NO If the answer is YES, please provide the following information for each such person: Name: Relationship: Employer: Weekly Earnings: 11. Include any other information which supports your claim that you cannot financially afford to employ an attorney. Rev. 2/3/05 3 American LegalNet, Inc. www.FormsWorkFlow.com NATURE OF YOUR CLAIM 12. Describe in your own words the nature of the claim which you are presenting to the court in your complaint/petition. (Additional space on next page) EFFORTS TO OBTAIN AN ATTORNEY The Court strongly suggests that you contact a minimum of three attorneys. 13. 14. Have you spoken with any attorney about handling your case? YES NO If your answer to #13 is YES, please provide the following information about each attorney with whom you spoke: a) Attorney's name Date you contacted this attorney Method of contact (in person, by telephone, etc.) Reason why attorney was not employed to handle your case b) Attorney's name Date you contacted this attorney Method of contact (in person, by telephone, etc.) Rev. 2/3/05 4 American LegalNet, Inc. www.FormsWorkFlow.com Reason why attorney was not employed to handle your case c) Attorney's name Date you contacted this attorney Method of contact (in person, by telephone, etc.) Reason why attorney was not employed to handle your case 15. Explain any other efforts you have made to obtain an attorney to handle your case. 16. Please provide any other information which supports your application for the court to appoint counsel. 17. Do you need a lawyer who speaks a language other than English? YES NO 5 Rev. 2/3/05 American LegalNet, Inc. www.FormsWorkFlow.com If you answered YES, what language do you speak? I declare under the penalties of perjury that my answers to the foregoing questions are true to the best of my knowledge. I understand that if I am assigned a lawyer and my lawyer learns, either from myself, or elsewhere, that I can afford a lawyer, the lawyer may give this in formation to the court. See Local Rule 83.10(b)(4) and (g). I understand that if my answers on my application to proceed in forma pauperis and/or on this application for appointment of counsel are false, my case may be dismissed. See 28 U.S.C. §1915(e). I hereby waive my privilege of attorney-client confidentiality to the extent necessary for my appointed attorney to make an application to be relieved from appointment as provided in Local Rules 83.10(c) and (d). I understand that filing this motion does not excuse me from litigating my case, and that it is still my responsibility to have the defendants served with process in accordance with Rule 4 of the Federal Rules of Civil Procedure, if I have not already done so. I also understand that filing this motion does not stay this case and does not excuse me from responding to any motion filed by the defendants. Date Original Signature of Movant Printed Name and Address of Movant If this motion is being filed AFTER the complaint has been served, the opposing party needs to be served with a copy of this motion and a certificate of service needs to be completed. I hereby certify that a copy of the foregoing motion was mailed to: Rev. 2/3/05 6 American LegalNet, Inc. www.FormsWorkFlow.com (List all defendants or counsel for defendants with address and date mailed.) Original Signature of Movant Rev. 2/3/05 7 American LegalNet, Inc. www.FormsWorkFlow.com