UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA _____________________________________________ (Plaintiff) v. AFFIDAVIT / DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS _____________________________________________ (Defendant) I, _______________________________________certify that I am the plaintiff in the above entitled case; that in support of my motion to proceed without being required to prepay fees, costs or give security therefor, I state that because of my present financial condition I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am entitled to redress. I further state that the responses which I have made to questions and instructions below are true and correct. 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. 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 life insurance payments? Yes _____ No _____ d. Gifts or inheritances? Yes _____ No _____ e. Any other sources? Yes _____ No _____ If the answer to any of the above is yes, describe each source of money and state the amount American LegalNet, Inc. www.FormsWorkflow.com received from each during the past twelve months. 3. Do you own any cash, or do you have money in a checking or savings account? Yes _____ No _____ (Include any funds in prison accounts.) If the answer is yes, state the amount of cash or the present balance in any account. ___________________________________________________________________________ ___________________________________________________________________________ 4. Do you 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. ___________________________________________________________________________ ___________________________________________________________________________ 5. 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. In order to comply with the court’s privacy policy, only the initials of a minor should be listed below. Also, listing the age of the minor is acceptable; however, only the year of birth may be included. See the court’s “Notice of Electronic Availability of Civil and Criminal Case File Information” and Local Rule 5.2 for more information on redaction of personal data identifiers. ___________________________________________________________________________ ___________________________________________________________________________ 6. List your monthly expenses for: food rent utilities child care medical care other (explain) __________ __________ __________ __________ __________ __________ ___________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 7. List any debts (mortgage, credit card, student loan, etc.) and the monthly fee on those debts: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ I understand that a false statement or answer to any questions in this affidavit/ unsworn declaration will subject me to penalties for perjury. I declare under penalty of perjury that the foregoing is true and correct. Executed on _____________________________ Date ______________________________ Signature of Plaintiff American LegalNet, Inc. www.FormsWorkflow.com