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Motion For Leave To Proceed In Forma Pauperis And Supporting Declaration Form. This is a Illinois form and can be use in USDC Southern Federal.
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Tags: Motion For Leave To Proceed In Forma Pauperis And Supporting Declaration, Illinois Federal, USDC Southern
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF ILLINOIS
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Plaintiff(s),
vs.
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_______________________________
_______________________________
Defendant(s).
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________________________
Case Number
MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS
AND SUPPORTING DECLARATION
I hereby apply for leave to commence this action for:
______ Civil Rights Relief
______ Other (Please describe):
_________________________________________________________________
without prepayment of fees and costs or giving security therefor.
In support of my motion, I state the following facts are true:
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1.
I am the party initiating said action and I believe that I am entitled to relief.
2.
The nature of this action is __________________________________________________
________________________________________________________________________
________________________________________________________________________
3.
I am unable to prepay the costs of this action or give security therefore because of my
poverty.
4.
I have no assets or funds which could be used to prepay the fees or costs, except:
(write “none” if you have nothing; otherwise list your assets)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
5.
Are you presently employed:
A.
month
______ yes
______ no
If the answer is “yes,” state the amount of your salary or average wages per
and give the name, address and telephone number of your employer.
Monthly earnings:
$_______________________
Employer Information
__________________________________________
__________________________________________
__________________________________________
B.
wages
If the answer is “no,” state the date of last employment, name, address and
telephone number of last employer, and the amount of the salary or average
per month which you received.
Date of last employment:
________________________
Monthly earnings:
$_______________________
Former Employer’s Information:
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__________________________________________
__________________________________________
__________________________________________
6.
Have you received within the last twelve months any money fro any of the following
sources?
A.
Business, profession or form of self employment?
______ yes
B.
______ no
Rent payments, interest or dividends?
______ yes
C.
______ no
Pensions, annuities or life insurance payments?
______ yes
______ no
D.
Social Security, Veterans Administration, disability pensions, workmen’s
compensation or unemployment benefits?
______ yes
______ no
E.
______ yes
______ no
F.
state
Gifts or inheritances?
Income from any other sources?
______ yes
______ no
If the answer to any of the above is “yes,” describe each source of money and
the amount received from each during the past twelve months:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
7.
Do you own any cash or do you have money in a checking or savings account?
______ yes
______ no
If the answer is “yes,” state the total value of the items owned:
________________________________________________________________________
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________________________________________________________________________
________________________________________________________________________
8.
Do you own real estate, stocks, bonds, notes, automobiles or other valuable property?
(Exclude ordinary household furnishings and clothing)
______ yes
______ no
If the answer is “yes,” describe the property and state its approximate value:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
9.
Describe any additional financial or other information regarding your ability to pay the
costs of this action (for example, persons who are dependent upon you for support):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I understand that a false statement or answer to any questions in this declaration will subject me
to penalties of perjury.
I DECLARE (OR CERTIFY, VERIFY OR STATE) UNDER PENALTY OR PERJURY
UNDER THE LAWS OF THIS UNITED STATES OF AMERICA THAT THE FOREGOING
IS TRUE AND CORRECT. (28 U.S.C. § 1746; 18 U.S.C. § 1621).
Executed at _____________________________ on ________________________________.
Location
Date
________________________________.
Signature
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