UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF FLORIDA , Affiant v. CASE NUMBER: (To be supplied by Clerk's Office) , Defendant(s) AFFIDAVIT OF INDIGENCY (EACH PLAINTIFF MUST COMPLETE A SEPARATE AFFIDAVIT OF INDIGENCY) I, , being first duly sworn, depose and make under oath the following application and affidavit, pursuant to Title 28 U.S.C. § 1915, to proceed in forma pauperis in the United States District Court for the Middle District of Florida. I am unable to make prepayment of fees and costs or to give security therefor, and it is my belief that I am entitled to redress, and that I have not, for the purpose of avoiding payment of said cost, divested myself of any property, monies, or any items of value. I. BRIEF STATEMENT OF THE NATURE OF THE ACTION: American LegalNet, Inc. www.FormsWorkFlow.com II. RESIDENCE: Affiant's address: (Street) (City) (State) (Zip Code) III. MARITAL STATUS: 1. 2. Single G Married G Separated G Divorced G If married, spouse's full name: IV. DEPENDENTS: 1. 2. 3. Number: Relationship to dependent(s): How much money do you contribute to your dependent's support on a monthly basis? $ V. EMPLOYMENT: (Information provided below applies to your present employment or last employment.) 1. Name of employer: a. Address of employer: (Street) (City) (State) (Zip Code) b. State how long affiant has been (was) employed by present (or last) employer? Years: c. Income: Monthly $ Months: or Weekly $ d. What is (was) affiant's job title? 2. If unemployed, date of last employment: American LegalNet, Inc. www.FormsWorkFlow.com 3. Is spouse employed? If so, name of employer: a. Income: Monthly $ or Weekly $ b. What is spouse's job title? 4. Are you and/or your spouse receiving welfare aid? If so, amount: VI. FINANCIAL STATUS: 1. Owner of real property (excluding ordinary household furnishings and clothing): a. Description: b. Full address: (Street) (City) c. In whose name? d. Estimated value: e. Total amount owed: Owed to: for for f. Annual income from property: 2. Other assets/property: a. Automobile: Make In whose name registered? Present value of car: Amount owed: Owed to: b. Total cash in banks, savings and loan associations, prisoner accounts, financial institutions, other repositories, or anywhere else: $ $ $ Model $ $ $ $ $ (State) (Zip Code) Monthly $ or Weekly $ American LegalNet, Inc. www.FormsWorkFlow.com c. List monies received during the last twelve (12) months into your hands, into banks, savings and loan associations, prisoner accounts, other financial institutions, or other sources as indicated below: Business, profession, or other forms of self employment: Rent payments, interest, or dividends: Pensions, annuities, or life insurance payments: Gifts or inheritances: Stocks, bonds, or notes: Other sources: 3. Obligations: a. Monthly rental on house or apartment: b. Monthly mortgage payments on house: 4. $ $ $ $ $ $ $ $ Other information pertinent to affiant's financial debts and obligations: (Creditor) (Total Debt) (Monthly Payment) (Creditor) (Creditor) Other (explain): (Total Debt) (Total Debt) (Monthly Payment) (Monthly Payment) VII. FOR PRISONER AFFIANTS ONLY: 1. 2. 3. Date(s) of incarceration: Estimated release or parole date: A copy of the prisoner's account statement containing all transactions in affiant's prisoner account for the six (6) months immediately preceding the filing of the Complaint or Petition must accompany this Affidavit. The account statement must be obtained from an authorized official of each prison at which the prisoner is or was confined during this period of time. The account statement must be in the form of a computer printout or bank ledger card prepared by the institution or an account statement prepared by an authorized officer of the American LegalNet, Inc. www.FormsWorkFlow.com institution. Failure to provide this account statement may result in the dismissal of this action. The requirement to submit the account statement does not negate the prisoner affiant's responsibility to ensure that the Affidavit Certificate found on page 6 of this Affidavit of Indigency is also properly executed and filed. VIII. ALL AFFIANTS MUST READ AND SIGN: I UNDERSTAND that any false statement(s) of a material fact contained herein may serve as the basis of prosecution and conviction for perjury or making false statements. FURTHER, I CERTIFY that all questions contained herein have been answered and are true and correct to the best of my knowledge and belief. Signature of Affiant STATE OF FLORIDA COUNTY OF THE FOREGOING INSTRUMENT WAS ACKNOWLEDGED BEFORE ME THIS DAY OF , 20 , BY (Insert Name of Person Acknowledged) WHO IS PERSONALLY KNOWN TO ME OR WHO HAS PRODUCED , AS IDENTIFICATION AND WHO (DID) (DID NOT) (State Type of Identification) TAKE AN OATH. NOTARY PUBLIC MY COMMISSION EXPIRES: American LegalNet, Inc. www.FormsWorkFlow.com ******** AFFIDAVIT CERTIFICATE (Prisoner Accounts Only) I HEREBY CERTIFY THAT (Name of Affiant) $ as of (date) , has the sum of on account to his credit at the institution where he is confined. I further certify that the above-named prisoner affiant has the following securities to his credit according to the records of this institution: Authorized Officer of Institution American LegalNet, Inc. www.FormsWorkFlow.com