UNITED STATES DISTRICT COURT WESTERN DISTRICT OF MISSOURI ) Plaintiff, Petitioner or Complainant ) ) vs. ) Case No. ) ) Defendant(s) or Respondent(s). ) AFFIDAVIT OF FINANCIAL STATUS I, , declare that I am the in the above-entitled case; that in support of my motion to proceed without being required to prepay fees, costsor give security therefore, I state that because of my poverty I am unable to pay the costs of saidproceedings or to give security thereof; that I believe I am entitled to relief. I further swear that the responses which I have made to the questions below and theinformation I have given relating to my ability to pay the costs of commencing and prosecuting thisaction are true. I. MARITAL STATUS AND PERSONAL DATA A. Single: Married: Separated: Divorced: B. Name of Spouse C. Age of plaintiff, petitioner or complainant: D. Age of spouse: E. Address of plaintiff, petitioner or complainant: Telephone: F. Address of spouse: Telephone: G. State name or names of dependents who live with you, their age, address,>>>> 2 relationship, and how much of their monthly support you provide: II. EMPLOYMENT A. Present employment: Name of employer: Address of employer: Employers telephone: Length of employment: Job title or description: Net Income: Monthly $ Weekly $ Gross Income: Monthly $ Weekly $ Does employer provide health insurance:Yes No If employer provides health insurance, describe coverage: B. Previous employment (Answer only if presently unemployed). Name of employer: Address of employer: Employers telephone: Length of employment: Job title or description: Net Income: Monthly $ Weekly $ Gross Income: Monthly $ Weekly $ C. Employment of spouse: Page 2>>>> 3 Name of employer: Address of employer: Employers telephone: Length of employment: Job title or description: Net Income: Monthly $ Weekly $ Gross Income: Monthly $ Weekly $ III. FINANCIAL STATUS (Answer questions on behalf of both the plaintiff, petitioner or complainant and spouse). A. Owner of real property? Yes No If yes - Description: Address: In whose name? Estimated value: Total amount owed: Owed to: Annual income from property: B. Owner of automobile:Yes No If yes - Number of automobiles owned: Make Model Year Make Model Year In whose name registered? Present value: Amount owed on the automobile(s): Owed to: Monthly payment(s): Page 3 >>>> 4C. Cash on hand: (Include checking and savings accounts) $ List names and addresses of banks and associations: State account numbers: D. Have you received within the past 12 months any money from any of the following sources: Yes No Rent payments, interest or dividends: Pensions, trust funds, annuities or life insurance payments? Gifts or inheritances? Welfare payments? ADC or other governmental child support? Unemployment benefits? Social Security benefits? Other sources? E. If the answer to any item in D above was "Yes", describe each source of money and state the amount received from each during the past 12 months: Page 4 >>>> 5IV. OBLIGATIONS A. Monthly rental on house or apartment: B. Monthly mortgage payments on house: Amount of equity in house: C. Monthly mortgage payments on other properties: $ Amount of equity in other properties: $ D. Household expenses: Monthly grocery expense: Monthly utilities: Gas: Electric: Water: Other: (Specify) E. Other debts and miscellaneous monthly expenses: TO WHOM OWED AND FOR WHAT REASON INCURRED? MONTHLY BALANCE DUE PAYMENTS V. OTHER INFORMATION PERTINENT TO FINANCIAL STATUS (Include information regarding stocks, bonds, savings bonds, either individually or jointly owned). Page 5 >>>> 6 I understand that a false statement or answer to any question in this affidavit in support of mymotion to proceed in this matter in forma pauperis will subject me to pe nalties of perjury. Signature of Plaintiff, Petitioner or ComplainantSubscribed and sworn to before me this day of , 20 . Page 6