IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND * Plaintiff(s) * vs. Civil No.: * Criminal No: Defendant(s) * ******** MOTION FOR COPY WORK AT THE EXPENSE OF THE UNITED STATES I request copies of the documents listed below at the expense of the United States. (Describe documents by case number, title, date, and any other information that may help locate them.) The reason I need the copies is: Attached is an affidavit showing I cannot afford to pay for the copies. (signature) ______________________________ (printed name) ______________________________ U.S. District Court (Rev. 12/2000) >>>> 2 AFFIDAVIT IN SUPPORT OF MOTION FOR COPY WORK I, , declare that because of my poverty, I am unableto pay the costs of the copies I have requested. In support, I answer the following questions: 1. Are you presently employed, including a prison job or other assignment that results in compensation of any sort? YES NO a. If you answered YES, list your employer or assignment and the amount of your wages. Employer/assignment: Monthly gross wages: Monthly net wages: b. If you answered NO, state the date of your last employment or assignment, the name of your employer or assignment, and the amount of wages you received. Date: Employer/assignment: Monthly gross wages: Monthly net wages: 2. Within the past twelve months have you received any income from: 1) settlements, judgments, or monetary awards from a court; 2) Social Security, public assistance, workers compensation or disability payments; 3) a business, profession or other form of self-employment; 4) rent, interest or dividends; 5) retirement, annuity, pension, or insurance payment; 6) gifts or inheritances; 7) or any other sources? YES NO U.S. District Court (Rev. 12/2000) >>>> 3 If you answered YES, list the amount received, date it was received, and the source. Amount Date received Source 3. How much money do you have in your prison account? 4. How much money do you have in checking, savings or other accounts outside of prison? 5. Do you own or have any interest in any real estate, stocks, bonds, notes, automobiles, or other valuable property (not including ordinary household furnishings and clothes)? YES NO If you answered YES, list the value and describe each item. Value Description 6. List everyone (including businesses and the government) that you owe money and the amount that you owe. Creditor Total debt Monthly payment 7. List any other major monthly expenses that you are actually paying.U.S. District Court (Rev. 12/2000) 2 >>>> 4 Description Monthly payment I DECLARE UNDER THE PENALTIES OF PERJURY THAT THE INFORMATION ABOVE IS TRUE AND CORRECT. (date) (signature) U.S. District Court (Rev. 12/2000) 3