IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND * Plaintiff vs. * Civil Action No. * Defendant ****** MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS Plaintiff hereby requests leave, pursuant to 28 U.S.C. §1915, to proceed “in forma pauperis” (without prepayment of costs). In support of this motion, plaintiff attaches an affidavit. Signature Name (Print or Type) Address City/State/Zip Phone No. Fax No. U.S. District Court (10/25/2007) Motion for Leave to Proceed "In Forma Pauperis" American LegalNet, Inc. www.FormsWorkflow.com IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND * Plaintiff vs. * Civil Action No. * Defendant ****** AFFIDAVIT IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS I, , declare that I am the plaintiff in the above-entitled case. I understand that the filing fee for most civil suits is $350.00. In support of my motion to proceed without being required to prepay the filing fee and other costs, I state that: (1) because of my poverty I am unable to pay such fee and costs, or give security therefor; and (2) I believe I am entitled to relief in this proceeding. The nature of my complaint is briefly stated as follows (employment discrimination, Social Security, civil rights, or other): In further support of this motion, I answer the following questions: 1. Are you presently employed? ‘ Yes ‘ No a. If the answer is “yes,” state the amount of your salary or wages per month, and give the name and address of your employer. List both gross and net (take-home) pay. Employer: Monthly Gross: $ Monthly Net: $ U.S. District Court (10/25/2007) Motion for Leave to Proceed "In Forma Pauperis" American LegalNet, Inc. www.FormsWorkflow.com b. If the answer is “no,” state the date of last employment, the name and address of your employer, and the amount of salary or wages per month you received. Date: Employer: Monthly Gross: $ Monthly Net: $ 2. Have you received within the past 12 months any income from: (1) settlements, judgments, or monetary awards following compensation, or disability payments; (2) Social Security, public assistance, workers’ compensation, or disability payments; (3) a business, profession or other form of self-employment; (4) rent payments, interest, or dividends; (5) retirement, annuity, pension or insurance payments; (6) gifts or inheritances; or (7) any other sources? ‘ Yes ‘ No Received: Source: $ $ $ $ Do you expect this income to continue: ‘ Yes ‘ No 3. Do you have any cash on hand, or money in savings or checking accounts? ‘ Yes ‘ No If yes, state total amount: $ 4. Do you own or have any interest in any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? ‘ Yes ‘ No If yes, give value and description: Value: Description: $ $ $ $ U.S. District Court (10/25/2007) Motion for Leave to Proceed "In Forma Pauperis" 2 American LegalNet, Inc. www.FormsWorkflow.com 5. List creditors, including banks, mortgage companies, charge accounts, etc.: Creditors: Total Debt: Monthly Payment: $ $ $ $ $ $ $ $ 6. List any major monthly expenditures not included in your answer to No. 5, such as food, insurance, utilities, rent, child support, alimony, etc.: Description: Monthly Payment: $ $ $ $ 7. Marital Status: ‘ Single ‘ Married ‘ Widowed ‘ Separate/Divorced List Persons you actually support and your relationship to them: Name: Relationship: 8. If married, is your spouse employed? ‘ Yes ‘ No If yes, how much does your spouse earn per month: Gross: $ Net: $ 9. If you are a minor under age 18, what is your parents’ or guardian’s approximate monthly income? Gross: $ Net: $ I understand the Court will not consider my Motion unless all the questions are answered. I declare under penalty of perjury that the information above is true and correct. Date U.S. District Court (10/25/2007) Motion for Leave to Proceed "In Forma Pauperis" Signature 3 American LegalNet, Inc. www.FormsWorkflow.com