Revised 05/01 WDNY UNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK (Name of Plaintiff or Petitioner) MOTION TO PROCEED IN FORMA PAUPERIS AND SUPPORTING AFFIRMATION v. __________-CV-_________ (Name of Defendant(s) or Respondent(s)) I, , (print or type your name) am the plaintiff/petitioner in the above-entitled case andhereby request the Courts permission to proceed in forma pauperis. In support of my motion to proceed without being required to prepay fees, costs, or give security therefor, I state that because of my povertyI am unable to pay the costs of this action or to give security therefor and that I believe I am entitled to redress.I further declare that the responses which I have made in this affirmation below are true.1. Are you presently employed? Yes No My Employers Name and Address is: My Gross Monthly Wages are: $ If you are not presently employed, state Your Last Date of Employment: Your Gross Monthly Wages at that time: Is your spouse presently employed? Yes No My Spouses Employers Name and Address is: My Spouses Gross Monthly Wages are $ 2. Have you received any money from any of the following sources within the past twelve months: a. Business, profession or self-employment? Yes No If yes, state source and amount received per month $ b. Rent payments, interest or dividends? Yes No If yes, state source and amount received per month $ c. Pensions, annuities, disability, or life insurance payments? Yes No If yes, state source and amount received per month $ d. Gifts or inheritances? Yes No If yes, state source and amount received per month $ e. Child Support? Yes No If yes, state amount received each month $ f. Government Benefits (Social Security, SSI, Welfare, AFDC, Veterans, etc.)? Yes No If yes, state source and amount received per month $ g. Friends, Relatives or any other source? Yes No If yes, state source and amount received per month $ If you have not received any money from any of the above sources, please explain how you are currently paying your expenses: 3. What is your total gross monthly income today: $ 4. How much cash do you have on hand? $ >>>> 25. How much money do you have in a checking account(s)? $ 6. How much money do you have in a savings account(s)? $ 7. If you are an inmate of a correctional facility, state the amount of funds in your inmate account (NOTE: prisoners must have inmate account balances certified by an authorized official of the correctional facility and must include a signed Authorization for payment of the filing fee): 8. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes No If so, describe the property in detail and give an estimated value of the property: If you own property, are you paying off a loan or mortgage on it? Yes No If yes where are you obtaining the money to make such payments: 9. If you are not an inmate, state your total monthly household expenses: Rent or mortgage $ Food $ Utilities $ All other expenses $ If your monthly expenses exceed the amount of income you listed in # 3 above, please explain how you are paying your expenses 10. List all of the people who are in your household and state the amount of money each one contributes to household expenses each month: 11. List the persons who are dependent upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support: 12. Have you been adjudicated bankrupt within the past ten (10) years? Yes No If the answer is yes, please include the court and date of filing I declare under penalty of perjury that the foregoing is true and correct. Executed on (Date) (Applicants Signature) PRISON CERTIFICATION SECTION (Required for Prisoner Requests Only; Prisoner Requests Must Have This Section Completed By Prison Official) I certify that the movant has the sum of $ on account to his/her credit at the Correctional Facility where s/he is currently confined. I further certify that the movant has the following securities to his/her credit according to the institutions records: . I further certify that the movants average account balance was $ during the last six months. Signature of Authorized Officer of Institution Print Name of Authorized Officer of Institution