IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF GEORGIA ________________________ DIVISION ______________________________________ (Plaintiff/Petitioner) vs. ______________________________________ ______________________________________ ______________________________________ ______________________________________ (Defendant(s)/Respondent(s)) : : : : : : : : : : : : : : : CIVIL ACTION NO: MOTION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT I, _____________________________________, being first duly sworn, depose and say that I am the plaintiff in the above-entitled case. As such, I motion to the Court to be allowed to proceed without the requirement to pre-pay fees or costs or give security due to my poverty which results in my inability to pay the costs of said proceeding or to give security. For this reason, I believe I am entitled to redress. I further declare that the responses which I make to the questions and instructions below are true. 1. Are you presently employed? Yes 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. If the answer is no, state the date you last worked and the amount of salary or wages per month which you received. ____________________________________________________________________________________ ____________________________________________________________________________________ 2. Have you received within the past TWELVE (12) months any money from any of the following sources? a. Business, profession, or form of self employment? b. Pension, annuities, or life insurance payments? c. Rent payments, interest, or dividends? d. Gifts or inheritances? e. Any other sources? Yes Yes Yes Yes Yes No No No No No American LegalNet, Inc. www.FormsWorkFlow.com If the answer to any of the above is yes, describe each source of money received and state the amount received from each during the past TWELVE (12) MONTHS. ____________________________________________________________________________________ ____________________________________________________________________________________ _______________________________________________________________________________________ 3. Do you have any cash, or do you have money in a checking, savings, or prison account? (You must attach a certificate from prison authorities if you have money in a prison account). Yes No If yes, how much do you have? $________________________ 4. Do you own any real estate (house and/or property), stocks, bonds, notes, auto-mobiles, or other valuable property, excluding ordinary household goods and furnishings? Yes No a. If the answer is yes, describe the property and state its approximate value. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ b. If the answer is yes, list any mortgages, liens, or loans against the property and state the amount you owe. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 5. List the persons who are dependent upon you for their support. State your relationship to those persons and indicate how much you contribute toward their support. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Signed this ___________ day of _____________________________, 20_________. ________________________________________ (Signature of Plaintiff) American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION UNDER PENALTY OF PERJURY YOU MUST DECLARE UNDER PENALTY OF PERJURY THAT THE ANSWERS YOU HAVE GIVEN IN THE ATTACHED MOTION/AFFIDAVIT FORM ARE TRUE AND CORRECT. GIVING A FALSE ANSWER OR FALSE INFORMATION IN RESPONSE TO ANY QUESTION WILL SUBJECT YOU TO FEDERAL PERJURY CHARGES. 18 U.S.C. § 1621 PROVIDES AS FOLLOWS: Whoever ... (2) in any declaration, certificate, verification, or statement under penalty of perjury as permitted under section 1746 or title 28, United States Code, willfully subscribes as true any material matter which he does not believe to be true; is guilty of perjury and shall, except as otherwise expressly provided by law, be fined not more than $2,000 or imprisoned not more than five years or both. This section is applicable whether the statement or subscription is made within or without the United States. Understanding the above, I declare under penalty of perjury that the foregoing answers and information provided by me in support of my request to proceed in forma pauperis are true and correct. Executed this ___________________ day of ____________________________, 20__________. ________________________________________ (Signature of Plaintiff) American LegalNet, Inc. www.FormsWorkFlow.com RETURN TO: DAVID W. BUNT, CLERK UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF GEORGIA P.O. BOX 128 MACON, GEORGIA 31202 RE: ______________________________ (Plaintiff) ______________________________ (Prisoner Number) ACCOUNT CERTIFICATION I hereby certify that the plaintiff/petitioner named herein above has an average monthly balance for the last six (6) months of $___________________________________ in account to his/her credit at the ________________________________ institution where he/she is confined. I further certify that the plaintiff/petitioner likewise has the following securities to his/her credit according to the records of this institution: ________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (If not confined for a full six (6) months, specify the number of months confined, then compute the average monthly balance based on that number of months): ___________________________________ _________________________________________