IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF KANSAS Plaintiff vs. Defendant(s) ) ) ) ) ) ) ) ) Case No. APPLICATION FOR LEAVE TO FILE ACTION WITHOUT PAYMENT OF FEES, COSTS OR SECURITY, WITH AFFIDAVIT OF FINANCIAL STATUS IN SUPPORT The above named plaintiff states that he/she is without means to pay the fees, costs or security to file an action against the above name defendant and that the plaintiff is justly aggrieved by action of the defendant. Plaintiff states that attached hereto is his/her affidavit of financial status in support of his/her application to the court for leave to file a civil action without payment of costs. 1 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT OF FINANCIAL STATUS , declare that I I, am the in the above entitled case: that in support of my motion 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 proceedings or to give security therefor: that I believe I am entitled to relief. I further swear that the responses which I have made to the questions below and the information I have given relating to my ability to pay the costs of commencing and prosecuting this action are true. I. MARITAL STATUS AND PERSONAL DATA: A. Single: B. Age of plaintiff D. Age of spouse E. Divorced: Name of spouse C. Separated: Address of plaintiff: Married: Telephone: F. Address of spouse: Telephone: G. State name or names of dependents who live with you, their age, address, relationship, and how much of their monthly support you provide: 2 American LegalNet, Inc. www.FormsWorkflow.com .. . ... .. . ... II. EMPLOYMENT A. Present employment: Name of employer: Address of employer: Employer's telephone: Length of employment: Job title or description: Net income: Monthly $ Weekly $ Gross income: Monthly $ Weekly $ Does employer provide health insurance? Yes No If employer provides health insurance, describe coverage: B. Previous employment (answer only if presently unemployed) . Name of employer: Address of employer: Employer's telephone: Length of employment: Job title or description: Net income: Weekly $ Gross income: Monthly $ C. Monthly $ Weekly $ Employment of spouse: Name of employer: Address of employer: Employer's telephone: Length of employment: Job title or description: Net income: Monthly $ Weekly: $ Gross income: Monthly $ Weekly: $ 3 American LegalNet, Inc. www.FormsWorkflow.com III. FINANCIAL STATUS (Answer questions on behalf of both the plaintiff and spouse.) A. Owner of real property? Yes If yes - No Description: Address: In whose name? Estimated value $ Total amount owed $ Owed to: Annual income from property $ B. Owner of automobile? Yes No If yes, number of automobiles owned: Make Model Year Make Model Year In whose name registered: Present value $ Amount owed on the automobile(s) $ Owed to: Monthly payment(s) $ C. Cash on hand: (Include checking and savings accounts) $ List names and addresses of banks and associations. State account numbers: 4 American LegalNet, Inc. www.FormsWorkflow.com D. Have you received within the past 12 months any money from any of the following sources? Yes No Rent payments, interest or dividends: Pensions, trust funds, annuities or life insurance payment: Gifts or inheritances? Welfare payments? ADC or other governmental child support? Unemployment benefits? Social Security benefits? Other sources? E. IV. If the answer to any item in D above was ''Yes'', describe each source of money and state the amount received from each during the past 12 months: OBLIGATIONS A. Monthly rental on house or apartment $ B. Monthly mortgage payments on house $ Amount of equity in house $ C. Monthly mortgage payments on other properties $ Amount of equity in other properties $ 5 American LegalNet, Inc. www.FormsWorkflow.com D. Household expenses: Monthly grocery expense $ Monthly utilities: Gas $ Electric $ Water $ Other: E. (Specify) Other debts and miscellaneous monthly expenses: Monthly Payment To whom owed and for what reason incurred V. Balance Due OTHER INFORMATION PERTINENT TO FINANCIAL STATUS (Include information regarding stocks, bonds, savings bonds, either owned individually or jointly owned). 6 American LegalNet, Inc. www.FormsWorkflow.com I understand that a false statement or answer to any question in this affidavit in support of my motion to proceed in forma pauperis will subject me to penalties of perjury. Signature of Plaintiff Name (Print or Type) Address City State Zip Code Telephone 7 American LegalNet, Inc. www.FormsWorkflow.com