UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSHIRE _____________________________________ Plaintiff v. Civil Action No. _______________________________ _____________________________________ Defendant(s) MOTION/AFFIDAVIT TO PROCEED IN FORMA PAUPERIS WITHOUT PREPAYMENT OF FEES I, ______________________________________________, declare that I am the plaintiff/petitioner/movant in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs 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 relief. In support of this application, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated? [ ] Yes [ ] No (If "No" go to Question 2) Name of Institution: ________________________________________________________________________ Are you employed at the institution? [ ] Yes [ ] No If "Yes" - do you receive any payment from the institution? [ ] Yes [ ] No If "Yes" - how much per month? $______________ You must attach a Certificate of Custodial Institution (USDCNH-14) completed by the institution of your incarceration. The institution will also supply a copy of your trust account statement for the preceding six months. Processing of your case will be delayed if this material is not attached. 2. Are you currently employed? (Skip this question if incarcerated) [ ] Yes [ ] No a. b. 3. If the answer is "Yes" - state the amount of your take-home salary or wages and pay period (i.e. per week, month, etc.) and give the name and address of your employer. If the answer is "No" - state the date of your last employment, the amount of your take-home salary or wages and pay period (i.e. per week, month, etc.) and the name and address of your last employer. In the past twelve months, have you received any money from any of the following sources? a. b. c. d. e. f. Business, profession or other self-employment Rent payments, interest or dividends Pensions, annuities or life insurance payments Disability or worker's compensation payments Gifts or inheritances Any other sources [ [ [ [ [ [ ] ] ] ] ] ] Yes Yes Yes Yes Yes Yes [ [ [ [ [ [ ] ] ] ] ] ] No No No No No No If the answer to any of the above is "Yes" - describe each source of money and state the amount received and what you expect you will continue to receive. USDCNH-13 (11-04) (Previous Editions Obsolete) American LegalNet, Inc. www.USCourtForms.com (continued on reverse) [ ] Yes [ ] No 4. Do you have any cash or checking or savings accounts? If "Yes" - state the total amount $_______________________ (PLEASE DO NOT LIST FINANCIAL ACCOUNT NUMBERS) 5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other valuable property, excluding ordinary household furnishings and clothing? [ ] Yes [ ] No If "Yes" - describe the property and state its value. 6. Do you have any other assets? If "Yes" - list each asset and state its value. 7. Do you have any outstanding debts? [ ] Yes [ ] No If "Yes" - list them. (If incarcerated, be sure to include any debts owed to the institution where you are incarcerated as a result of disciplinary or other action.) 8. List your regular monthly household or other expenses: 9. List the persons who are dependent on you for support, state your relationship to each person, and indicate how much you contribute to their support. If you are listing minor children as dependents, please list only the initials of the minor child (not full name) [ ] Yes [ ] No I declare under penalty of perjury that the above information is true and correct. I understand that a false or dishonest answer to a question in this affidavit may be punishable by fine or imprisonment or both. ____________________________ DATE USDCNH-13 (11-04) (Previous Editions Obsolete) ________________________________________________________________ SIGNATURE OF APPLICANT American LegalNet, Inc. www.USCourtForms.com