IFP/Civ. Rev. 9/01 IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF NORTH CAROLINA v. ) ) ) ) Plaintiff, ) ) ) ) ) ) ) ) ) ) Defendant(s) ) APPLICATION FOR LEAVE TO PROCEED IN FORMA PAUPERIS AND AFFIDAVIT/DECLARATION IN SUPPORT I, __________________________, request leave of Court to proceed in the aboveentitled action without prepayment of fees and costs or giving security therefor. In support of this request, I state that I am unable to pay such costs or give security therefor and that I believe that I am entitled to redress. The nature of this action is . I understand that any false statement or answer to any question in this application may subject me to the penalties for perjury. 1. Are you presently employed? Yes ___ No ___ a. If the answer is yes, state the amount of your salary or wages per month, and give the name and address of your employer. b. If the answer is no, state the date of last employment and the amount of the salary and wages per month which you received. 2. Is your spouse presently employed? Yes ___ No ___ No spouse ___ a. If the answer if yes, state the amount of spouse’s salary or wages per month, and give the name and address of spouse’s employer. b. If the answer is no, state the date of last employment and the amount of salary and wages per month which your spouse received. American LegalNet, Inc. www.USCourtForms.com 3. Have you received within the past twelve months any money from any of the following sources: a. Business, profession, or form of self-employment? Yes___No___ b. Rent payments, interest, or dividends? Yes___No___ c. Pensions, annuities, or insurance? Yes___No___ d. Social Security, SSI or disability? Yes___No___ e. Workers’ Compensation or Unemployment? Yes___No___ f. Child support? Yes___No___ g. AFDC, WIC or Food Stamps? Yes___No___ h. Gifts or inheritances? Yes___No___ i. Any other sources? Yes___No___ If the answer to any of the above is yes, describe each source of money and state the amount received from each during the past twelve months. 4. Has your spouse received within the past twelve months any money from any of the sources listed in question No. 3? Yes ____ No ____ No spouse ____ If the answer to any of the above is yes, describe each source of money and state the amount received from each during the past twelve months. 5. Do you and your spouse, if any, own any cash, or have money in a checking, savings, or any other financial account? Yes ____ No ____ If the answer is yes, state the total value of the items owned. -2American LegalNet, Inc. www.USCourtForms.com 6. Do you and your spouse, if any, own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes ____ No ____ If the answer is yes, describe the property and state its approximate value. 7. 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. 8. List your debts, obligations, and creditors, including banks, loan companies, charge accounts, and monthly bills. Creditor Total Debt Monthly Payment ____________________________ ___________________ _______________ ____________________________ ___________________ _______________ ____________________________ ___________________ _______________ ____________________________ ___________________ _______________ ____________________________ ___________________ _______________ ____________________________ ___________________ _______________ ____________________________ ___________________ _______________ I declare under penalty of perjury that the foregoing is true and correct. Executed on ______________________. (Date) ___________________________________ (Signature of Plaintiff) -3American LegalNet, Inc. www.USCourtForms.com