UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI , Plaintiff(s), v. , Defendant(s). ) ) ) ) ) ) ) ) ) No. MOTION TO PROCEED IN FORMA PAUPERIS AND FINANCIAL AFFIDAVIT I, , hereby apply for leave to proceed in this action without prepayment of fees or costs and without giving security therefor. In support of this application, I declare that the following facts are true: (1) I am the plaintiff in this case and I believe I am entitled to relief. (2) Because of my poverty I am unable to prepay the costs of this proceeding or to give security therefor. (3) The nature of my action, defense, or appeal is briefly stated as follows: I declare under penalty of perjury that the foregoing is true and correct. Executed on , 20 . Signature of plaintiff American LegalNet, Inc. www.FormsWorkflow.com CJA 23 FINANCIAL AFFIDAVIT Rev. 5/98 IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE G MAGISTRATE IN UNITED STATES G DISTRICT G APPEALS COURT or G OTHER PANEL (Specify below) IN THE CASE OF LOCATION NUMBER FOR  V.S. AT 1 G Defendant—Adult 2 G Defendant - Juvenile PERSON REPRESENTED (Show your full name)  DOCKET NUMBERS Magistrate 3 G Appellant 4 G Probation Violator CHARGE/OFFENSE (describe if applicable & check box )  5 G Parole Violator 6 G Habeas Petitioner G Felony G Misdemeanor District Court Court of Appeals 7 G 2255 Petitioner 8 G Material Witness 9 G Other (Specify) ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY Are you now employed? G Yes Name and address of employer: EMPLOYMENT G No G Am Self-Employed IF YES, how much do you earn per month? $ IF NO, give month and year of last employment How much did you earn per month? $ G Yes If married is your Spouse employed? IF YES, how much does your Spouse earn per month? $ G No If a minor under age 21, what is your Parents or Guardian’s approximate monthly income? $ Have you received within the past 12 months any income from a business, profession or other form of self-employment, or in the form of the form of rent payments, interest, dividends, retirement or annuity payments, or other sources? G Yes G No ASSETS OTHER INCOME CASH RECEIVED IF YES, GIVE THE AMOUNT RECEIVED & IDENTIFY THE SOURCES SOURCES $ G Have you any cash on hand or money in savings or checking accounts? Yes G No IF YES, state total amount $ Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? G Yes G No PROPERTY OBLIGATIONS & DEBTS  VALUE DESCRIPTION IF YES, GIVE THE VALUE AND $ DESCRIBE IT DEPENDENTS DEBTS & MONTHLY BILLS (LIST ALL CREDITORS, INCLUDING BANKS, LOAN COMPANIES, CHARGE ACCOUNTS, ETC.)   Total No. of Dependents MARITAL STATUS SINGLE  MARRIED WIDOWED SEPARATED OR DIVORCED APARTMENT OR HOME: List persons you actually support and your relationship to them Creditors Total Debt Monthly Paymt. $ $ $ $ $ $ $ $ I certify under penalty of perjury that the foregoing is true and correct. Executed on (date) SIGNATURE OF DEFENDANT (OR PERSON REPRESENTED)  American LegalNet, Inc. www.FormsWorkflow.com