UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF GEORGIA _________________________ Plaintiff/Petitioner, v. _______________________________ Defendant/Respondent. : : : : : AFFIDAVIT IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS; AUTHORIZED WITHDRAWAL FORM; CERTIFIED AFFIDAVIT OF INMATE ACCOUNT STATUS. AFFIDAVIT AND AUTHORIZATION FOR WITHDRAWAL FROM INMATE ACCOUNT I, ___________________________, being first duly sworn or under penalty of perjury, affirm and say that I am the plaintiff/petitioner in the above-styled action; that in support of my motion to proceed without prepayment of fees or costs or give security therefor pursuant to Title 28 U.S.C.§ 1915 (a)(1), I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therfor. I further swear or affirm that the responses which I have made to the questions below are true. 1. Are you presently employed? Yes ( ) No () a. If employed, state the amount of your salary or wages per month and give the address of your employer.___________________________________________________________ _______________________________________________________________________ b. 2. If you are not currently employed, state the date of your last employment and the amount of salary or wages received. _______________________________________________________________________ Have you received within the past twelve months any money from any of the following sources? a. Business, profession or self-employment? Yes( ) No( ) b. Rent, payments, interest or dividends? Yes( ) No( ) c. Pensions, annuities or life insurance? Yes( ) No( ) d. Gifts or inheritances? Yes( ) No( ) e. Any other source? Yes( ) No( ) If you answered yes to any of the above, describe each source and state the amount received from each._____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. Do you own any cash, or do you have money in a checking or savings account? (Include funds in prison account.) Yes ( ) NO ( ) If the answer is yes, state the total value of items owned. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property, excluding ordinary household furniture and clothing? Yes ( ) No ( ) If the answer is yes, describe the property and state is approximate value. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5. List the persons who are dependent upon you for support, state your relationship to each person, and indicate how much you contribute toward their support. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ AUTHORIZATION FOR ACCOUNT WITHDRAWAL I hereby authorize my custodian and his/her designee to withdraw funds from my inmate account and to transmit the same to the Clerk, United States District Court to be applied to the filing fee which I am required to pay in connection with this case. This authorization shall apply to any institution in which I am or may be confined. Executed this ________ day of ___________________________, 20 _____. ________________________________ Signature of Plaintiff/Petitioner PLAINTIFF/PETITIONER IS REQUIRED TO SUBMIT WITH THIS AFFIDAVIT AND AUTHORIZATION A CERTIFIED COPY OF HIS/HER INMATE ACCOUNT STATEMENT FOR THE SIX MONTH PERIOD IMMEDIATELY PRECEDING THE FILING OF THIS COMPLAINT. CERTIFICATE I hereby certify that the plaintiff/petitioner herein has a current balance of $__________in his/her inmate account at the _______________________________Institution. Plaintiff has an average monthly balance for the preceding six months of $____, and the average monthly deposits to said account for the preceding six months are $_____. I further certify that plaintiff has the following assets to his/her credit according to the records of this institution:___________________________________________________ ___________ Date _____________________________________________ Authorized Officer of Institution American LegalNet, Inc. www.FormsWorkFlow.com