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In Forma Pauperis Application And Financial Affidavit Form. This is a Illinois form and can be use in USDC Northern Federal.
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Tags: In Forma Pauperis Application And Financial Affidavit, Illinois Federal, USDC Northern
UNITED STATES DISTRICT COURT FOR THE
NORTHERN DISTRICT OF ILLINOIS
11/06/08
IN FORMA PAUPERIS APPLICATION
AND
FINANCIAL AFFIDAVIT
_____________________________,
Plaintiff
v.
Case Number: ________________________
_____________________________,
Defendant(s)
Judge:
________________________
Instructions: Please answer every question. Do not leave any blanks. If the answer is “none” or
“not applicable (N/A),” write that response. Wherever a box is included, place an X in whichever
box applies. If you need more space to answer a question or to explain your answer, attach an
additional page that refers to each such question by number and provide the additional information.
Please print or type your answers.
Application: I, _______________________________________, declare that I am the G plaintiff
G petitioner G movant (other______________________) in the above-entitled case. This affidavit
constitutes my application G to proceed without full prepayment of fees, or G in support of my
motion for appointment of counsel, or G both. I declare that I am unable to pay the costs of these
proceedings, and I believe that I am entitled to the relief sought in the
complaint/petition/motion/appeal. In support of my application, I answer the following questions
under penalty of perjury.
1.
G Yes
G No
(If “No,” go to Question 2)
I.D. #: __________________ Name of prison or jail: _____________________________
Do you receive any payment from the institution?
G Yes
G No
Monthly amount: ___________
2.
Are you currently employed?
G Yes G No
a.
If the answer is “yes,” state your:
Monthly salary or wages: ___________________
Name and address of employer: ________________________________________
__________________________________________________________________
Are you currently incarcerated?
b.
If the answer is “no,”state your:
Beginning and ending dates of last employment: ___________________________
Last monthly salary or wages: ___________________________________________
Name and address of last employer: _____________________________________
__________________________________________________________________
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3.
Are you married?
G Yes
G No
If the answer is “yes,” is your spouse currently employed? G Yes
G No
Spouse’s monthly salary or wages: ______________________________________
Name and address of spouse’s employer: _________________________________
__________________________________________________________________
4.
In addition to your income stated above in response to Question 2 (which you should not
repeat here), have you or anyone else living at the same residence received more than $200
in the past twelve months from any of the following sources? Mark an X next to “Yes” or
“No” in each of the categories a. through g, check all boxes that apply in each category, and
fill in the twelve-month total in each category.
a.
G Salary or G wages
GYes
GNo
Amount: _______________ Received by: _______________________________
b.
G Business, G profession or G other self-employment
GYes
GNo
Amount: _______________ Received by: _______________________________
c.
G Rental income, G interest or G dividends
GYes
GNo
Amount: _______________ Received by: _______________________________
d.
G Pensions, G social security, G annuities, G life insurance, G disability,G workers’
compensation, G alimony or maintenance or G child support
GYes
GNo
Amount: _______________ Received by: _______________________________
e.
G Gifts or G inheritances
GYes
GNo
Amount: _______________ Received by: _______________________________
f.
G Unemployment, G welfare or G any other public assistance
GYes
GNo
Amount: _______________ Received by: _______________________________
g.
G Any other sources (describe source:___________)
GYes
GNo
Amount: _______________ Received by: _______________________________
5.
Do you or anyone else living at the same residence have more than $200 in cash or checking
or savings accounts?
GYes
GNo
Total amount: __________________________
In whose name held: _____________________ Relationship to you: __________________
6.
Do you or anyone else living at the same residence own any stocks, bonds, securities or
other financial instruments?
GYes
GNo
Property: _________________________ Current value: ____________________________
In whose name held: _____________________ Relationship to you: __________________
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7.
Do you or anyone else living at the same residence own any real estate (with or without a
mortgage)? Real estate includes, among other things, a house, apartment, condominium,
cooperative, two-flat, etc.
GYes
GNo
Type of property and address: _______________________________________
Current value: __________________________ Equity: ___________________ (Equity is
the difference between what the property is worth and the amount you owe on it.)
In whose name held: ______________________ Relationship to you: __________________
Amount of monthly mortgage or loan payments: _________________________________
Name of person making payments: _____________________________________________
8.
Do you or anyone else living at the same residence own any automobiles with a current
market value of more than $1000?
GYes
GNo
Year, make and model: ____________________________________________________
Current value: _________________________ Equity: ___________________ (Equity is
the difference between what the automobile is worth and the amount you owe on it.)
Amount of monthly loan payments: ________________________
In whose name held: ______________________ Relationship to you: __________________
Name of person making payments: _____________________________________________
9.
Do you or anyone else living at the same residence own any boats, trailers, mobile homes
or other items of personal property with a current market value of more than $1000?
GYes
GNo
Property: __________________________________________________________
Current value: __________________________ Equity: ___________________ (Equity is
the difference between what the property is worth and the amount you owe on it.)
Amount of monthly loan payments: ________________________
In whose name held: ______________________ Relationship to you: __________________
Name of person making payments: _____________________________________________
10.
List the persons who live with you who are dependent on you for support. State your
relationship to each person and state whether you are entirely responsible for the person’s
support or the specific monthly amount you contribute to his or her support. If none, check
here: G None.
________________________________________________________________________
______________________________________________________________________
11.
List the persons who do not live with you who are dependent on you for support. State your
relationship to each person and state how much you contribute monthly to his or her support.
If none, check here: G None.
________________________________________________________________________
________________________________________________________________________
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I declare under penalty of perjury that the above information is true and correct. I understand that
28 U.S.C. § 1915(e)(2)(A) states that the court shall dismiss this case at any time if the court
determines that my allegation of poverty is untrue.
Date: _______________________
___________________________________
Signature of Applicant
___________________________________
(Print Name)
NOTICE TO PRISONERS: In addition to the Certificate below, a prisoner must also attach a
print-out from the institution(s) where he or she has been in custody during the last six months
showing all receipts, expenditures and balances in the prisoner’s prison or jail trust fund accounts
during that period. Because the law requires information as to such accounts covering a full six
months before you have filed your lawsuit, you must attach a sheet covering transactions in your
own account – prepared by each institution where you have been in custody during that six-month
period. As already stated, you must also have the Certificate below completed by an authorized
officer at each institution.
CERTIFICATE
(Incarcerated applicants only)
(To be completed by the institution of incarceration)
I certify that the applicant named herein, ____________________, I.D.#_______________, has the
sum of $ _____________ on account to his/her credit at (name of institution)
____________________________. I further certify that the applicant has the following securities
to his/her credit: ______________. I further certify that during the past six months the applicant’s
average monthly deposit was $ _______________. (Add all deposits from all sources and then
divide by number of months).
_______________________
Date
__________________________________________
Signature of Authorized Officer
__________________________________________
(Print Name)
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