IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF FLORIDA DIVISION , Plaintiff, vs. CASE NO: , , . Defendant(s). / MOTION TO PROCEED IN FORMA PAUPERIS I, , Plaintiff in the above-entitled action, move to proceed in forma pauperis pursuant to 28 U.S.C. § 1915 in the above-entitled action. I am unable to make full prepayment of fees or to give security therefore, and it is my belief that I am entitled to relief. I have not divested myself of any property, monies, or any items of value for the purpose of avoiding payment of said fees. I am hereby submitting a financial affidavit in support of this motion. Signature of Plaintiff AFFIDAVIT OF FINANCIAL STATUS MUST BE SUBMITTED WITH THIS MOTION. American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF FLORIDA DIVISION . (Enter full name of Plaintiff) vs. CASE NO: (To be assigned by Clerk) , , , . (Enter name and title of each Defendant. If additional space is required, use the blank area below and directly to the right.) AFFIDAVIT OF FINANCIAL STATUS The undersigned, with knowledge that there are criminal penalties for false statements, makes the following statement regarding my residence, marital status, employment, and financial status: I. RESIDENCE: Plaintiff's address: Street Apt. Zip Code City State Phone ( ) Do you own this property, rent, or live with family or friends? rev. 11/2010 American LegalNet, Inc. www.FormsWorkFlow.com II. MARITAL STATUS and DEPENDENTS: 9 a. b. III. Single Dependants: 9 Spouse 9 Children 9 Others 9 Married Separated 9 Divorced 9 How many: How many: EMPLOYMENT: Are you now employed? (Either through self-employment or through an employer) 9 Employed through an employer 9 Self-employed 9 Not employed If you are employed, provide information about current employer. If not, provide information about your most recent employer: Name of Employer: Address of Employer: Employer's Phone # ( ) Job title or description: Dates of employment: Beginning _________ Ending _________ Monthly earnings (including overtime pay, commission and tips) $ ___ ______ IV. FINANCIAL STATUS: 1. Do you own Real Property: 9 9 Yes No Description: Address: In whose name is the property titled: Estimated value: $ Annual income from property $ Amount owed on the property: $ 2. Do you own an Automobile: Make : __ Paid to: 9 Yes Model: 9 No Year: In whose name registered: Present value of car: $ Amount owed: $ 2 American LegalNet, Inc. www.FormsWorkFlow.com 3. Other Assets: Cash on hand: $ Possess credit cards: 9 Yes 9 No Cash in Bank/Savings & Loan Assoc./Credit Union: $ Names of Bank, Credit Union, and/or Savings & Loan Association: Name: City: Name: City: 4. Monthly Financial Obligations: a. Monthly rent on house/apartment: $ b. Monthly utilities expenses: $ c. Monthly telephone expenses: Mortgage: $ $ d. Monthly Car expenses: Car Payment $________ Gasoline:$ Car Insurance: $ e. Medical and/or Dental Insurance: $ f. Non-covered medical and/or dental expenses: g. Food and clothing $ h. Child care expenses: $ $ i. Child support payments: $ j. Alimony payments: 5. $ Other debts or monthly expenses: (for example, student loans, credit card debt, etc.): To whom owed: Amount: To whom owed: Amount: To whom owed: Amount: To whom owed: Amount: Total monthly payments on debts and expenses: . . . . . $ 6. Sources of income (other than those listed above): a. Total payments for support assistance such as Social Security Disability benefits, A.F.D.C., unemployment benefits, etc. $ b. per week $ per month Retirement benefits, including Social Security: $ per week $ per month 3 American LegalNet, Inc. www.FormsWorkFlow.com c. Amount of alimony, child support payments received: $ d. per week $ per month Other income (royalties, dividends, interest, trust fund, etc.): Source: per week $ per month Source: e. $ $ per week $ per month Do you regularly receive funds from a family member or friend? Yes If so, amount: $ 9 No 9 How often: 7. Spouse: a. If applicable, is your spouse employed: Yes b. Monthly Employment Income: $ No 9 N/A 9 Place of employment: c. 9 d. Other monthly income $ . 8. Other information pertinent to Plaintiff's financial status: Use this space to (1) describe any sporadic sources of income including odd jobs, seasonal or contract work; (2) list ownership of recreational vehicles, stocks, bonds, or trusts in which Plaintiff has an interest and (3) identify any other property of value. 9. Have you paid – or will you be paying – an attorney or anyone other than an attorney (including a paralegal or typist) any money for services in connection with this case, including the completion of this form? Yes 9 No 9 If yes, how much $ __________ If yes, provide the person’s name, address and telephone number: V. I HEREBY DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS AND INFORMATION PROVIDED ARE TRUE AND CORRECT. SIGNED: DATE: 4 American LegalNet, Inc. www.FormsWorkFlow.com Notice of Electronic Availability of Civil and Criminal Case File Information Effective Date: November 1st , 2004 Revised November 14th , 2006 The United States District Court for the Northern District of Florida accepts electronically filed pleadings and makes the content of these pleadings available on the court’s Internet website via the Case Management/Electronic Case Files (“CM/ECF”) system and/or PACER.1 Any subscriber to CM/ECF and/or PACER will be able to read, download, store, and print the full content of electronically filed documents. The clerk’s office will not make electronically available documents that have been sealed or otherwise restricted by court order. You should not include sensitive information in any document filed with the court unless such inclusion is necessary and relevant to the case. You must remember that any personal information not otherwise protected will be made available over the Internet via CM/ECF and/or WebPACER. If sensitive information must be included, the following personal data identifiers must be partially redacted from the document, whether it is filed traditionally or electronically: Social Security numbers, financial account numbers, dates of birth, the names of minor children, and home addresses of parties. Disclosure of financial account and real property information in public electronic records, as is necessary to properly identify property in foreclosure and forfeiture proceedings, is an allowable exception. In compliance with the E-Government Act of 2002, a party wishing to file a document containing the personal data identifiers specified above may (a) file an unredacted document under seal, or (b) file a reference list under seal. The court may, however, still require the party to file a redacted copy for the public file. In addition, exercise caution when filing documents that contain the following: 1. Personal identifying number, such as driver’s license number; 2. Medical records, treatment and diagnosis; 3. Employment history; 4. Individual financial information; and 5. Proprietary or trade secret information. Counsel are strongly urged to share this notice with all clients so that an informed decision about the inclusion of certain materials may be made. If a redacted document is filed, it is the sole responsibility of counsel and the parties to be sure that all pleadings comply with this notice requiring redaction of personal data identifiers. Likewise, counsel and the parties will be solely responsible for any unredacted documents filed. The Clerk’s Office will not review documents for compliance with this notice, seal on its own motion documents containing personal identifiers, or redact documents, whether filed electronically or on paper. 1 Remote electronic access to pleadings filed in civil social security cases is limited to counsel of record and court staff. Non-parties have direct access to the pleadings on file at the Clerk’s Office American LegalNet, Inc. www.FormsWorkFlow.com