MIED (Rev. 8/08) Application to Proceed In Forma Pauperis - Habeas Petitions, 2255 Motions and Nonprisoner Civil Cases UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MICHIGAN Plaintiff(s), Case No. v. Judge Magistrate Judge Defendant(s). / APPLICATION TO PROCEED IN FORMA PAUPERIS For use by incarcerated applicants filing habeas petitions or appeals from the denial or dismissal of habeas petitions or motions under 28 U.S.C. § 2255 and nonprisoners filing civil cases or appeals. THIS APPLICATION IS FOR (check one): Motion Under 28 U.S.C. § 2255 Appeal “ Habeas Action New Case “ Appeal “ Nonprisoner Action New Case “ Appeal “ declare that I am the: I, petitioner/plaintiff/appellant “ other “ in the above-entitled proceeding. In support of my request to proceed in forma pauperis under 28 U.S.C. § 1915, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought. In support of this application, I have provided answers to the following questions. 1. Are you employed? Yes “ No “ If your answer is yes, state the amount of your monthly pay and provide the name and address of your employer. Salary: Name of Employer: Employer’s Address: 2. In the last 12 months, have you received money from any of the following sources? a. b. c. d. e. Business, profession or other self-employment Rent payments, interest or dividends Pensions, annuities or life insurance payments Gifts or inheritances Other sources Yes Yes Yes Yes Yes “ “ “ “ “ No No No No No “ “ “ “ “ American LegalNet, Inc. www.FormsWorkflow.com MIED (Rev. 8/08) Application to Proceed In Forma Pauperis - Habeas Petitions, 2255 Motions and Nonprisoner Civil Cases If you answered yes to any of these questions, state the source of the money and the amount that you received. Source: Amount: 3. Do you have any money in a: a. b. c. Prison or jail account Checking account Savings account Yes “ Yes “ Yes “ No “ No “ No “ If you answered yes, state the total amount. Amount: 4. Do you own or have any interest in real estate, stocks, bonds, notes, vehicles, or other valuable property or assets (excluding ordinary household furnishings and clothing)? Yes “ No “ If you answered yes, describe the property and state its approximate value. Value: Value: Property description: Property description: 5. List the people who are dependent on you for support, state your relationship to each person and how much you contribute to their support. Relationship: Relationship: Relationship: Relationship: Amount: Amount: Amount: Amount: I declare under penalty of perjury that the foregoing is true and correct. Date: Signature of Applicant and Prisoner No. if applicable Address (including name of Institution) City, State, Zip Code Telephone Number REQUEST FOR SERVICE BY U.S. MARSHAL For use only by nonprisoners filing new civil cases. If my application to proceed In Forma Pauperis is granted: a. Date: I request service of the summons and complaint by a U.S. Marshal. Yes “ No “ Signature of Applicant American LegalNet, Inc. www.FormsWorkflow.com MIED (Rev. 8/08) Application to Proceed In Forma Pauperis - Habeas Petitions, 2255 Motions and Nonprisoner Civil Cases CERTIFICATE This section only applies to incarcerated applicants filing habeas petitions or appeals from the denial or dismissal of habeas petitions or motions under 28 U.S.C. § 2255. (To be completed by an authorized prison official.) I certify that the applicant named herein has the sum of $ on account to his/her credit at (name of institution) I further certify that the applicant has the following securities to his/her credit at this institution: . . Date: Signature and Title of Authorized Official Name of Institution American LegalNet, Inc. www.FormsWorkflow.com