Form 106A SUPERIOR COURT OF THE DISTRICT OF COLUMBIA FAMILY COURT and CIVIL DIVISION _________________________________________ Plaintiff/Petitioner v. _______________________________ Defendant/Respondent APPLICATION TO PROCEED WITHOUT PREPAYMENT OF COSTS, FEES, OR SECURITY (In Forma Pauperis) Form 106A I, ___________________________________________ am the (check one) Plaintiff/Petitioner Defendant/Respondent I need an interpreter for this case. _______________ [Insert Language]. I speak the following language: Case no:________________ I respectfully ask permission to proceed in this case without pre-paying costs or fees and without giving security for them because I am not able to do so without substantial hardship to myself or to my family. In support of this request, I state the following: Check and answer only those that apply. INCOME 1. I receive the following public benefits, and the law presumes that I am eligible to proceed without prepayment of costs, fees, or security (see D.C. Code � 15-712): Temporary Assistance for Needy Families (TANF) General Assistance for Children (GAC) Program on Work, Employment and Responsibility (POWER) Supplemental Security Income (SSI) American LegalNet, Inc. www.FormsWorkFlow.com 2. Even though I do not receive the above public benefits, I receive the following similar benefits and, therefore, request that my Application be approved: Interim Disability Assistance (IDA) because my SSI application has not been approved/certified Medicaid DC Healthcare Alliance or the following similar health benefits (describe)__________________________________________. If you checked any of the above boxes, you do not need to answer any more questions and may skip to the section called "Declaration." Otherwise, you must answer the rest of the questions on this form. If additional information is required, you will be notified. 3. My total income over the past 12 months from all sources (including, but not limited to, my job, other wages or business income, rental income, pensions, annuities or life insurance payments, worker's compensation, unemployment compensation or insurance, annual interest or dividends, gifts, alimony or spousal support, inheritance or trust income) is $_________. 4. I am presently unemployed. The last date I worked was on _______________, _______. Month Year DEPENDENTS 5. How many people live in your household and depend on you for support: ________. Of these people, how many are minor children or elderly? ________. 2 Form 106A American LegalNet, Inc. www.FormsWorkFlow.com ASSETS 6. I state the following about my property: I have $__________ in cash, including money in savings or checking accounts. I own the vehicles, personal home, other real estate, stock, bonds, or other valuable property, besides household furnishings and clothing, listed below: _________________________________________________________ _________________________________________________________ _______________________________________________________. List the Property EXPENSES 7. This is my best estimate of the monthly expenses for myself and the people in my household who depend on me for support: Housing (rent, mortgage, taxes, & insurance): $________ Public Transportation and Gasoline: $__________ Automobile Loan, Insurance, Maintenance: $__________ Health (medical, dental, vision, prescriptions, insurance): $________ Food and other Household Necessities: $__________ Utilities (including gas, electric, water, phone, internet): $_________ Clothing: $__________ Child Support: $____________ Childcare (including diapers, daycare): $___________ Other (explain in detail): $_________________________________ Total Estimated Monthly Expenses: $___________ 3 Form 106A American LegalNet, Inc. www.FormsWorkFlow.com OTHER SPECIAL CIRCUMSTANCES 8. (Optional) Explain any other special circumstances that you want to have considered in support of your request, including any large monthly expenses, debts, wage or bank account garnishments, and/or judgments. ________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________. 4 Form 106A American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION REQUIRED: I solemnly swear or affirm under criminal penalties for the making of a false statement, which includes 180 days in jail or a $1,000 fine or both, that I have read this Application and that the factual statements made in it are true to the best of my personal knowledge, information and belief. 1 __________________________________________ Signature __________________________________________ Address __________________________________________ Phone Number __________________________________________ Date POINTS AND AUTHORITIES IN SUPPORT OF APPLICATION TO PROCEED WITHOUT PREPAYMENT OF COSTS, FEES, OR SECURITY 1. 2. 3. 4. 5. 6. 7. 8. D.C. Code � 15-712. D.C. Code � 22-2405. Civil Rule 54-II, Domestic Relations Proceedings Rule 54-II, and Family Rule R. Adkins v. E.I. Du Pont de Nemours & Co., Inc., 335 U.S. 331 (1948). Harris v. Harris, 137 U.S. App. D.C. 318, 322, 424 F.2d 806 (1970), cert. denied, 400 U.S. 826 (1970) ("in forma pauperis relief not limited to those who are public charges or absolutely destitute"). Green v. Green, 562 A.2d 1214 (D.C. 1989) (statute "effectuates the fundamental principle that every litigant should be provided equal access to the courts without regard to financial ability"). Herbin v. Hoeffel, 727 A.2d 883, 887 (D.C. 1999) (court officers serve process in in forma pauperis cases). Cabillo v. Cabillo, 317 A.2d 866, 866 (D.C. 1974) (per curiam) (reversing denial of in forma pauperis status and mandating granting of petition where litigant's income "only slightly above the welfare standard"). 1 When you come to court, you may be asked questions about this Application. If your responses are not truthful, you could face additional criminal penalties. 5 Form 106A American LegalNet, Inc. www.FormsWorkFlow.com SUPERIOR COURT OF THE DISTRICT OF COLUMBIA FAMILY COURT and CIVIL DIVISION _________________________________________ Plaintiff/Petitioner v. _______________________________ Defendant/Respondent ORDER Having considered Plaintiff/Petitioner's Defendant/Respondent's Case No.________________ Application to Proceed without Prepayment of Costs, Fees, or Security, it is hereby ordered that the Appli