FORM #1 United States Bankruptcy Court Western District of Michigan {INSERT BANKRUPTCY CASE/ADVERSARY PROCEEDING CAPTION} APPLICATION TO PROCEED WITH PRO BONO MEDIATION (WITHOUT PAYING FEES OR COSTS) I declare, under penalty of perjury, that I am unable to pay the fees or costs of these proceedings and I am entitled to the relief requested. In support of this application, I make the following representations under penalty of perjury. 1. Current bankruptcy case. If you are a debtor in a case currently pending, please state the case number, chapter (chapter 7, 11, 12 or 13), and district in which it is pending: . (Case Number) (Chapter) (District) Additionally, for the remaining questions, you may provide copies of your schedules and note any additional information which is required, or any updates or changes. 2.Income from employment. I am employed/not employed (circle one). If employed, answer the following questions. a. My employer's name and address are: b. My gross pay or wages are $ , and my take-home pay or wages are $_______________ per (specify pay period) . c. I do/do not (circle one) expect a change in income in the next 12 months. 3. Other income. I have received (in the past 12 months) or will receive (in the next12 months), money from the following sources (check all that apply): Past 12 mos. Next 12 mos. Business, profession, or other self-employment Rent payments, interest or dividends Pension, annuity or life insurance payments Disability, or worker's compensation payments Gifts or inheritances Tax refunds Per capita or other payments from a Tribe, Band, etc. Any other sources (describe): _______________________ _______________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Pro Bono Mediation Application Case No. _______________ A/P No. (if any) _________________ If you checked a box for any of the above sources of money, describe below (or on separate pages) each and every source of money you have received, the amount you have received, and any amounts you expect to receive in the future. 4. Amount of money I have in cash or in any checking or savings accounts: $______________. 5. I own the following property (describe the property and its approximate value, and include any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or thing of value, and including any item of value held in someone else's name): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 6. My regular monthly expenses for housing, transportation, utilities, loan payments and all other regular monthly expenses are (describe and provide the amount of the monthly expenses here or on another sheet): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship with each person, and how much I contribute to their support: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 8. Any debts or financial obligations (describe the amounts owed and to whom they are payable): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Declaration: I declare under penalty of perjury that the above information is true. I understand that a false statement may result in dismissal of my claims or entry of a default judgment against me. Date: ____________________ _______________________________ Applicant's signature 2 American LegalNet, Inc. www.FormsWorkFlow.com