United States District Court WESTERN DISTRICT OF KENTUCKY NON-PRISONER APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT ____________________, Plaintiff v. CASE NUMBER: ____________________, Defendant(s) I, ______________________________, swear or affirm under penalty of perjury that I am the (check appropriate box) ” petitioner/plaintiff/movant ” other _________________ in the above-named proceeding, that I am unable to pay the costs of these proceedings, and that I believe I am entitled to the relief sought in the complaint/petition/motion. I further swear or affirm under penalty of perjury under United States laws that my answers on this form and any attachments are true and correct. Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is “0”, “none,” or “not applicable (N/A),” write in that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name and the question number. NOTE: You should be prepared to provide the Court with copies of documents that support or verify all your answers to the questions in this application. Signed: ________________________________ Date: ___________________________ Print your Name: ________________________ 1. State the address of your legal residence ___________________________________________________________________________________________ ___________________________________________________________________________________________ Your daytime phone number: 2. ___________________________ For both you and your spouse, estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. Income Source Average monthly amount during the past 12 months YOU Amount expected next month SPOUSE YOU SPOUSE Employment $ $ $ $ Self-employment $ $ $ $ Income from real property (such as rental income) $ $ $ $ Interest & dividends $ $ $ $ Page 1 of 5 American LegalNet, Inc. www.USCourtForms.com Income Source Average monthly amount during the past 12 months YOU Amount expected next month SPOUSE YOU SPOUSE Gifts or Inheritance $ $ $ $ Alimony $ $ $ $ Child support $ $ $ $ Retirement (such as social security, pensions, annuities, insurance) $ $ $ $ Disability (such as social security, insurance payments) $ $ $ $ Unemployment payments $ $ $ $ Public assistance (such as welfare) $ $ $ $ Other (specifiy) ___________________ ___________________ $ $ $ $ Total Monthly Income $ $ $ $ ” Yes ” Yes ” No ” No 3. Are you currently employed? Is your spouse currently employed? 4. List your employment history, current or, if you are not currently employed, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Address Dates of Employment Gross Monthly Pay a. $____________________ b. $____________________ c. $____________________ Page 2 of 5 American LegalNet, Inc. www.USCourtForms.com . List your spouse’s employment history, current or, if your spouse is not currently employed, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Address Dates of Employment Gross Monthly Pay a. $ __________________ b. $ __________________ c. $ __________________ 6. How much cash do you and your spouse have? $ ___________________ Below, state any money you or your spouse have in checking or savings accounts or in any other financial institution. Financial Institution Type of Account Amount You Have Amount Your Spouse Has a. $ __________________ $ __________________ b. $ __________________ $ __________________ c. $ __________________ $ __________________ 7. List the assets, and their values, that you own or your spouse owns. Do not list clothing and ordinary household furnishings. Asset Description Value a. Home $ __________________ b. Real Estate $ __________________ c. Motor Vehicle Make & Year: Model: Registration #: $ __________________ d. Motor Vehicle Make & Year: Model: Registration #: $ __________________ e. Other Assets (for example, stocks, bonds, securities or other financial instruments) $ __________________ f. Other Assets $ ____________________ Page 3 of 5 American LegalNet, Inc. www.USCourtForms.com 8. State every person, business, or organization owing you or your spouse money, and the amount owed. Who owes you or your spouse money? Amount owed to you Amount owed to your spouse a. $ __________________ $ __________________ b. $ __________________ $ __________________ c. $ __________________ $ __________________ d. $ __________________ $ __________________ 9. State the persons who rely on you or your spouse for support. Name Relationship Age Amount Contributed Monthly for His/Her Support a. $ ____________________ b. $ ____________________ c. $ ____________________ d. $ ____________________ 10. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any amount that was received weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate. Expense Rent or home mortgage payment (include lot rented for mobile home) You $ _______________________ Your Spouse $ ______________________ Are real estate taxes included? ” Yes ” No Is property insurance included? ” Yes ” No Utilities (electricity, heating fuel, water, sewer, telephone) $ _______________________ $ _______________________ Home maintenance (repairs and upkeep) $ _______________________ $ _______________________ Food $ _______________________ $ _______________________ Clothing $ _______________________ $ _______________________ Laundry and dry cleaning $ _______________________ $ _______________________ Medical and dental expenses $ _______________________ $ _______________________ Transportation (not including motor vehicle payments) $ _______________________ $ _______________________ Recreation, entertainment, newspapers, magazines, etc. $ _______________________ $ _______________________ Page 4 of 5 American LegalNet, Inc. www.USCourtForms.com Expense Insurance (not deducted from wages or included in mortgage payments. Homeowner’s or renters: Life: Health: Motor Vehicle: Other: You Your Spouse $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _________________________ $ _________________________ $ _________________________ $ _________________________ $ _________________________ $ _________________________ $ _________________________ $ _________________________ Alimony, maintenance, and support paid to others $ _________________________ $ _________________________ Regular expenses for the operation of business, profession, or farm (attach detailed statement) $ _________________________ $ _________________________ Other (specify): ______________________________ $ _________________________ $ _________________________ TOTAL MONTHLY EXPENSES $ _________________________ $ _________________________ Taxes (not deducted from wages or included in mortgage payments)(specify):_______________ ______________________________ Installment payments Motor Vehicle: Credit Card(s) (name): ________________________ ________________________ Department Store (name): ________________________ ________________________ Other: __________________ 11. Do you expect any major changes to your or your spouse’s monthly income or expenses, or in your or your spouse’s assets or liabilities during the next 12 months? ” Yes ” No If yes, describe on an attached sheet. 12. Have you paid – or will you be paying – an attorney any money for services in connection with this case, including the completion of this form? ” Yes ” No If yes, how much? $ ___________________ If yes, state the attorney’s name, address and telephone number: ___________________________________________________________________________________________ ___________________________________________________________________________________________ 13. Have you paid – or will you be paying – anyone other than an attorney (such as a paralegal or typist) any money for services with this case, including the completion of this form? ” Yes ” No If yes, how much? $ ___________________ If yes, state the person’s name, address and telephone number: ___________________________________________________________________________________________ ___________________________________________________________________________________________ 14. Provide any other information that will help explain why you cannot, or cannot without undue hardship, pay the fees or costs for this case. Page 5 of 5 American LegalNet, Inc. www.USCourtForms.com