DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK _______________________________________________ (petitioner/plaintiff) -v- _______________________________________________ (respondent(s)/defendant(s)) I, ________________________________________________, am the petitioner/plaintiff in the above entitled case. In support of my motion to proceed without being required to prepay fees or costs or give security therefore, I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therefore, that I believe I am entitled to redress. I declare that the responses which I have made below are true. 1. If you are presently employed, state the amount of your salary wage per month, and give the name and address of your last employer. YOU MUST ANSWER THIS QUESTION EVEN IF YOU ARE INCARCERATED. _____________________________________________________________________________ 2. If you are NOT PRESENTLY EMPLOYED, state the date of last employment and amount of the salary per month which you received AND how long the employment lasted. YOU MUST ANSWER THIS QUESTION EVEN IF YOU ARE INCARCERATED. IF YOU HAVE NEVER BEEN EMPLOYED, SAY SO. _____________________________________________________________________________ 3. Have you every received, within the past twelve months, any money from any of the following sources? a. b. c. d. e. f. 5/99 Business, profession, or form of self-employment? Rent payments, interest, or dividends? Pensions, annuities, or life insurance payments? Gifts or inheritances? Any form of public assistance? Any other sources? YES____ YES____ YES____ YES____ YES____ YES____ NO____ NO____ NO____ NO____ NO____ NO____ 2001 (C) American LegalNet, Inc. If the answer to any of the questions in part three is yes, describe each source of money and state the amount received from each during the past months. _____________________________________________________________________________ 4. Do you own any cash or do you have money in a checking or savings account? YES____ NO____ (Including any funds in prison accounts) If the answer is yes, state the total value owned. _____________________________________________________________________________ 5. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (including ordinary household furnishings and clothing)? YES____ NO____ If the answer is yes, describe the property and state its approximate value. _____________________________________________________________________________ 6. List the person(s) who are dependent upon you for support, state your relationship to those person(s), and indicate how much you contribute toward their support at the present time. _____________________________________________________________________________ 7. If you live in a rented apartment or other rented building, state how much you pay each month for rent. Do not include rent contributed by other people. _____________________________________________________________________________ 8. State any special financial circumstances which the court should consider in this application. _____________________________________________________________________________ I understand that a false statement or answer to any questions in this declaration will subject me to the penalties for perjury. I declare under penalty of perjury that the foregoing is true and correct. Signed this _________ day of ________________________, __________. (day) (month) (year) _______________________________________ (signature) 5/99 2 2001 (C) American LegalNet, Inc.