UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK ------------------------------------------------------------X Plaintiff, APPLICATION FOR THE COURT TO REQUEST COUNSEL -againstCV ( ) Defendant(s). ------------------------------------------------------------X 1. Name of applicant _________________________________________________________________ 2. Explain why you feel you need a lawyer in this case. (Use additional paper if necessary.) __________________________________________________________________________________ __________________________________________________________________________________ _________________________________________________________________________________ 3. Explain what steps you have taken to find an attorney and with what results. (Use additional paper if necessary.) ________________________________________________________________________________ __________________________________________________________________________________ _________________________________________________________________________________ 4. If you need a lawyer who speaks in a language other than English, state what language you speak: _________________________________________________________________________________ 5. I understand that if a lawyer volunteers to represent me and my lawyer learns that I can afford to pay for a lawyer, the lawyer may give this information to the Court. I understand that if the Court grants this application in a complaint against the Commissioner of Social Security, the pro bono attorney, if successful, has the statutory right to request that the Court award a fee of up to 25% of the accrued Social Security or Supplemental Security Income Benefits. See 42 U.S.C. § 406. 6. I understand that if my answers on my Request to Proceed In Forma Pauperis are false, my case may be dismissed. 7. I declare under penalty of perjury that the forgoing is true and correct. Dated: ___________________ ____________________________________________ Signature American LegalNet, Inc. www.FormsWorkflow.com rev. 7/08 UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK ------------------------------------------------------------X Plaintiff, REQUEST TO PROCEED IN FORMA PAUPERIS IN SUPPORT OF THE APPLICATION FOR THE COURT TO REQUEST COUNSEL -againstCV ( ) Defendant(s). ------------------------------------------------------------X I, _________________________________________ (print or type your name) am the plaintiff/defendant in the above-entitled case and I hereby request to proceed in forma pauperis and without being required to prepay fees or costs or give security. I state that because of my poverty I am unable to pay the costs of said proceeding or give security therefor, and that I believe I am entitled to redress. 1. If you are presently employed, give the name and address of your employer and state the amount of earnings per month. _______________________________________________________________________________ _______________________________________________________________________________ 2. If you are not presently employed, state the date you were last employed and your earnings per month at that time. You must answer this question even if you are incarcerated. _______________________________________________________________________________ _______________________________________________________________________________ 3. Have you received, within the past twelve months, any money from any source? If so, name the source and the amount of money you received. _______________________________________________________________________________ a) Are you receiving any public benefits? G No G Yes, $_________________ b) Do you receive any income from any other source? G No G Yes, $_________________ rev. 7/08 American LegalNet, Inc. www.FormsWorkflow.com 4. Do you have any money, including money in a checking or savings account? If so, how much? _______________________________________________________________________________ 5. Do you own any apartment, house or building, stocks, bonds, notes, automobiles or other valuable property? If the answer is yes, describe the property and state its approximate value. G No G Yes, $_________________________________________________________________ 6. Do you pay for rent or for a mortgage? If so, how much each month? G No G Yes, $_________________________________________________________________ 7. List the person(s) that you pay money to support and the amount you pay each month. _______________________________________________________________________________ _______________________________________________________________________________ 8. State any special circumstances which the Court should consider. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ I understand that the Court may dismiss this case if I give a false answer to any question in this declaration. I understand that if the Court grants this application in a complaint against the Commissioner of Social Security, the pro bono attorney, if successful, has the statutory right to request that the Court award a fee of up to 25% of the accrued Social Security or Supplemental Security Income Benefits. See 42 U.S.C. § 406. I declare under penalty of perjury that the foregoing is true and correct. Dated: _____________________ __________________________________________ Signature rev. 7/08 American LegalNet, Inc. www.FormsWorkflow.com UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK -------------------------------------------------------- X Plaintiff, AFFIRMATION OF SERVICE -againstCV ( ) Defendant(s). -------------------------------------------------------- X I,_____________________________________ (print or type your name), declare under penalty of perjury that I have served a copy of the attached Application for the Court to Request Counsel upon the defendant(s) or the attorney for defendant(s) whose address is: by ____________________________________________________________________________________ (describe how you served document: For example - personal delivery, mail, overnight express, etc.) Dated: ___________________________________________ Signature ___________________________________________ Address ___________________________________________ ____________________________________________ City, State & Zip Code rev. 7/08 American LegalNet, Inc. www.FormsWorkflow.com