REQUEST FORM TO PROCEED IN FORMA PAUPERIS CIVIL ACTION INSTRUCTIONS – READ CAREFULLY (NOTE: O.C.G.A. §9-10-14(a) requires the proper use of this form, and failure to use this form as required will result in the clerk of any court refusing to accept the action for filing.) 1. Any action filed by an inmate of a state or local penal or correctional institution against the state or a local government or against any agency or officer of a state or local government must be filed on the appropriate form or forms promulgated by the Administrative Office of the Courts of Georgia. 2. This application must be legibly handwritten or typewritten, and signed by the petitioner. Any false statement of a material fact may serve as the basis for prosecution for perjury. All questions must be answered concisely in the proper space on the form. 3. O.C.G.A. §42-12-1 et seq. provides that an inmate’s institutional account shall be frozen, and funds seized for court costs and fees. Additionally, the filing of frivolous litigation shall result in a deduction from the account. 4. This affidavit of indigency must be accompanied by a certification from the institution wherein the inmate is incarcerated that the financial statement correctly states the amount of funds in any and all custodial accounts held with the institution. 5. Any Request Form to Proceed In Forma Pauperis which does not conform to these instructions will be returned with a notation as to the deficiency. 6. In no event shall a prisoner file any action in forma pauperis in any court of this state if the prisoner has, on three or more prior occasions while he or she was incarcerated or detained in any facility, filed any action in any court of this state that was subsequently dismissed on the grounds that such action was frivolous or malicious, unless the prisoner is under imminent danger of serious physical injury. O.C.G.A. §42-12-7.2. 7. These forms may be obtained at the Administrative Office of the Courts’ website (http://www.georgiacourts.org/forms.html#inmate) or from the Administrative Office of the Courts through the head of the institution in which the inmate is incarcerated. American LegalNet, Inc. www.FormsWorkflow.com IN THE SUPERIOR COURT OF ___________________________ STATE OF GEORGIA ____________________________________ , Plaintiff ____________________________________ , Inmate Number Civil Action No. _________________________ vs. ____________________________________ , Nature of Action: _______________________________________ ____________________________________ , _______________________________________ ____________________________________, Defendant(s) _______________________________________ REQUEST TO PROCEED IN FORMA PAUPERIS I, ____________________________________, depose and say that I am the plaintiff in the above entitled case; that in support of my request to proceed without being required to prepay fees, costs, or give security therefor, I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am entitled to redress. I further swear that the responses which I have made to questions and instructions below are true. 1. List any and all aliases by which you are known: _____________________________________ ______________________________________________________________________________ 2. Are you presently employed? Yes No If the answer is “Yes,” state the amount of your salary or wages per month, and give the name and address of your employer: __________________________________________ ________________________________________________________________________ If the answer is “No,” state the date of last employment and the amount of the salary and wages per month which you received: _________________________________________ ________________________________________________________________________ 3. Have you received within the past twelve months any money from any of the following sources? Business, profession, or form of self-employment? Yes No Pensions, annuities, or life insurance payments? Yes No Rent payments, interest or dividends? Yes No Administrative Office of the Courts (Revised 02-10-2009) [1] Form CA-2 American LegalNet, Inc. www.FormsWorkflow.com Gifts or inheritances? Yes No Any other sources? Yes No If the answer to any of the above is “Yes,” describe each source of money and state the amount received from each source during the past twelve months: __________________ ________________________________________________________________________ ________________________________________________________________________ 4. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison accounts): Yes No If the answer is “Yes,” state the total value of the items owned: _____________________ 5. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes No If the answer is “Yes,” describe the property and state its approximate value: __________ ________________________________________________________________________ ________________________________________________________________________ 6. List the persons who are dependant upon you for financial support, state your relationship to those persons, and indicate how you contribute toward their support: _______________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I understand that a false statement or answer to any question in this affidavit will subject me to penalties for perjury and that state law provides as follows: a. A person to whom a lawful oath or affirmation has been administered commits the offense of perjury when, in a judicial proceeding, he knowingly and willfully makes a false statement material to the issue on point in question b. A person convicted of the offense of perjury shall be punished by a fine of not more than $1,000 or by imprisonment for not less than one nor more than ten years, or both. O.G.C.A. § 16-10-70. _________________________________ Signature of Plaintiff Administrative Office of the Courts (Revised 02-10-2009) [2] _____________ Date Form CA-2 American LegalNet, Inc. www.FormsWorkflow.com VERIFICATION I, _____________________________________ , do swear and affirm under penalty of law that the statements contained in this affidavit are true. I further attest that this application for in forma pauperis status is not presented to harass or to cause unnecessary delay or needless increase in the costs of litigation. I am the plaintiff in this action and know the content of the above Request to Proceed in Forma Pauperis. I verify that the answers I have given are true of my own knowledge, except as to those matters that are stated in it on my information and belief, and as to those matters I believe them to be true. I have read the perjury statute set out above and am aware of the penalties for giving any false information on this form. _________________________________ Signature of Affiant Plaintiff _____________ Date Sworn to and subscribed before me this _______ day of ______________, 20____. ___________________________________________________ Notary Public or Other Person Authorized to Administer Oaths Please note that under O.G.C.A. § 42-12-5 service of an affidavit in forma pauperis, including all attachments, shall be made upon the court and all named defendants. Failure by the prisoner to comply with this code section shall result in dismissal without prejudice of the prisoner’s action. Administrative Office of the Courts (Revised 02-10-2009) [3] Form CA-2 American LegalNet, Inc. www.FormsWorkflow.com THIS FORM IS TO BE COMPLETED ONLY BY AN AUTHORIZED INDIVIDUAL AT THE INSTITUTION WHERE THE INMATE PLAINTIFF IS PRESENTLY INCARCERATED, OR HIS/HER DESIGNEE. CERTIFICATION I hereby certify that the Plaintiff herein, ____________________________________________, has an average monthly balance for the last twelve (12) months of $ ___________________ on account at the __________________________________________________________________________________ ______________________________________ institution where confined. (If not confined for a full twelve (12) months, specify the number of months confined. Then compute the average monthly balance on that number of months.) I further certify that Plaintiff likewise has the following securities according to the records of said institution: ___________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ___________________________________ Authorized Officer of Institution _________________ Date NOTE: Please attach a copy of the prisoner’s inmate account of the last 12 months, or the period of incarceration (whichever is less). Administrative Office of the Courts (Revised 02-10-2009) [4] Form CA-2 American LegalNet, Inc. www.FormsWorkflow.com