Superior Court of the District of Columbia CIVIL DIVISION I Plaintiff vs. Civil Action No. Defendant AFFIDAVIT IN SUPPORT OF MOTION TO PROCEED IN FORMA PAUPERIS I further swear that the responses which I have made to questions and instructions below relating to my ability to pay the cost of proceeding in this action are true. 1. Are you presently employed? Yes 0 No a. If the answer is yes, state the amount of your salary or wages per month, and give the name and address of your employer. b. 2. If the answer is no, state the date of last employment and the amount of the salary and wages per month which you received Have you received within the past twelve months any money from any of the following sources? a. Business, profession or form of self-employment? Yes No b. Rent payments, interest or dividends? Yes 0 No C. Pensions, annuities or life insurance payments? Yes No 0 d. Gifts or inheritance? Yes 0 No 0 e. Any other sources? Yes No 0 If the answer to any of the above is yes, describe each source of money and state the amount received form each during the past twelve months. Form CV(6k6941Nov 66 9.1473 wd-314 2001 © American LegalNet, Inc. 3. Do you own any cash, or do you have money in checking or savings account? Yes No (Include any funds in prision accounts). If the answer is yes, state the total value of the items owned. 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes No If the answer is yes describe the property and state its approximate value. 5. List the persons who are dependent upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support. I have read and subscribed to the above and swear, under oath, that the information is true and correct. I understand that a false statement or answer to any question in this affidavit will subject me to penalties for perjury. (Plaintiff's signature) being first duly sworn under oath, presents that he has read and subscribed to the above add states that the information herein is true and correct. (Plaintiff's signature) SUBSCRIBED AND SWORN TO before me this day of Notary Public or other person authorized to administer an oath 2001 © American LegalNet, Inc.