UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF MISSISSIPPI CIVIL ACTION NO. APPLICATION FOR LEAVE TO FILE SUIT UNDER TITLE VII OF THE CIVIL RIGHTS ACT OF 1964 WITHOUT PAYMENT OF FEES , COSTS, OR SECURITY AND FOR APPOINTMENT OF AN ATTORNEY My name is . I know that there are criminalpenalties for making false official statements. With that knowledge, I hereby apply to the United States District Court for the Northern District of Mississippi for appointment of a lawyer and for leave to file suitagainst (Insert Defendants Name and Address) under Title VII of the Civil Rights Act of 1964 without payment of fees or costs or giving security therefor. In support of this application, I submit the following information under oath (check appropriate boxes): 1. Marital Status: G Single G Married G Separated G Divorced2. Dependents: G Spouse G Children (Number: ) G Others 3. I am a resident of the State of .4. My home address is: (Street or P.O. Box No.) (City) (State) (ZIP)5. Employment: G I am not employed G I am employed by (Employers name) (Employers Address) I have been employed by this employer since The name of my job is My income is $ G Monthly G Weekly G Per hour6. Financial Status: A. Real Property >>>> 2 G I do not own any real property G I own the following real property: 1. Description: 2. Address: 3. Name of property owner(s): 4. Estimated value: $ 5. Total amount owed on property: $ Owed to: 6. I receive $ each year from this property. B. Other Property 1. Automobile: Brand Name Model Year 2. Registered owners name: 3. Present value of car: $ Amount owed: $ Owed to: Monthly payment: $ Number of payments remaining: C. Cash 1. I have $ cash on hand. 2. I have $ in the following bank or credit union or savings association:D. Stocks, Bonds, Insurance Money, Veterans Benefits, Social Security, and Other Benefits G I have the following stocks, bonds, or other investments: G I receive $ from stocks, bonds, or other investments G I receive $ from insurance G I receive $ from the Veterans Administration G I receive $ from Social Security G I receive $ from -2- >>>> 3 E. Debts and Obligations G I own my home. My monthly mortgage payment is $ G I rent my home. My monthly rent payment is $ G I do not owe any other debts. G I have the following debts $ Payable to $ Payable to $ Payable to $ Payable to $ Payable to $ Payable to $ Payable to $ Payable to The total of my monthly payments, including rent or mortgage, car payments, and all other debts is $ 7. Statement of Discrimination Claim. My discrimination claim is stated in my Complaint.8. I tried diligently to hire a lawyer, with the following results: (Check all that apply) G I contacted the following private lawyers who specialize in labor law, employment discrimination law, or civil rights law, but they would not take my case because: LAWYERS NAME & ADDRESS REASON FOR REFUSING TO TAKE MY CASE -3- >>>> 4 G I contacted the Legal Services Corporation (tel. 662. 234-2918), but they would not take my case because: G I contacted the Mississippi Bar Association Lawyer Referral Service (1-800 682-6423). The Service gave me the names of the lawyers listed below. I contacted the lawyers but they would not take my case because: LAWYERS NAME & ADDRESS REASON FOR REFUSING TO TAKE MY CASE9. I have the following education (check highest level attained): Did not graduate from high school, but completed the grade. G -4- >>>> 5 GED (Date attained: ). G High school graduate (Year graduated: ). G Attended college or community college(Total hours credit: ). G Specialty or technical school(Field of study: ). G Specialty degree or technical skill or certification: College graduate College: Year: G College post-graduate education G 10. I request that the court grant me leave under Title VII of the Civil Rights Act of 1964 to file my lawsuit without payment of fees or costs or giving security therefor and that the court appoint a lawyer for me as is allowed by law. Signature I declare or certify or verify or state under penalty of perjury that the foregoing is true and correct. Date signed: Signature -5-