UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS PURSUANT TO 28 U.S.C. § 1915 , Plaintiff(s), v. Case No. , Defendant(s). I request leave to commence this civil action without prepayment of fees, costs, or security therefor pursuant to 28 U.S.C. § 1915. In support of my request, I submit the attached financial affidavit and state that: (1) (2) (3) I am unable to pay such fees, costs, or give security therefor. I am entitled to commence this action against the defendant(s). I request that the court direct the United States Marshal's Service to serve process. Original Signature Name (print or type) Street Address City ( State Zip Code ) Telephone Number Rev.1/11/08 1 American LegalNet, Inc. www.FormsWorkflow.com 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. § 1915 , 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: Wife ____ Children # ____ Others # ____ and relationship ______________________________________________ Please provide the names and ages of your children. IF A CHILD IS A MINOR (UNDER AGE 18), PLEASE IDENTIFY THE CHILD BY INITIALS ONLY. Name ____________________________________ Age ______ Name ____________________________________ Age ______ Name ____________________________________ Age ______ RESIDENCE Street Address: _______________________________________________ City: __________________________ State: ________________________ Zip Code: _______________ Telephone: __________________________ Rev.1/11/08 2 American LegalNet, Inc. www.FormsWorkflow.com 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: _________________________ Income: Monthly ___________________ Weekly ___________________ If self-employed state weekly wages: ______________________________ What is the nature of your employment? _________________________ If unemployed at present, complete the following: I have been unemployed since the ____ day of ___________, 19_____ The name of my last employer: ____________________________________ Address: ____________________________________________________ Telephone #: ( ) The last salary or wages received: ______________________________ If spouse is employed, please complete the following: Name of employer: _______________________________________________ How long employed: ___________________________ Income: 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 ____ If yes, description: ________________________________________________ Address: ________________________________________________________ In whose name? __________________________________________________ Estimated value: __________________________________________________ Amount owed: ____________________________________________________ Rev.1/11/08 3 American LegalNet, Inc. www.FormsWorkflow.com 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:_________________________ $_________________ 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: $_________________ Rev.1/11/08 4 American LegalNet, Inc. www.FormsWorkflow.com 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. 5. 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 Rev.1/11/08 5 American LegalNet, Inc. www.FormsWorkflow.com