MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS I, _____________________________________________________do hereby request leave to proceed in forma pauperis and state under oath that I am unable to pay the costs for commencement of this _____________________ action, or to give security therefor, and that I believe I am entitled to redress. I further state the following: I am not employed ( ) or I am employed by: _______________________________________________________ and my salary is $ ________________________ per _________________________. I have no other sources of income except the following (include public assistance, social security disability, or any other income not included above employment and state the amount): __________________________________________________________________________________ ________________________________________________________________ ________________________________________________________________ I have $________________________________ IN CASH. I have the following funds in the bank: NAME OF THE BANK TYPE OF ACCOUNT AMOUNT $ $ $ I own the following valuable property (include real estate, stocks, bonds, notes, automobiles, and other valuable property, but exclude ordinary household furnishings and clothing): VALUE $ $ $ I have the following debts: American LegalNet, Inc. www.USCourtForms.com I have the following dependents: NAME RELATIONSHIP AGE ____________________________________ Plaintiff I declare under penalty of perjury that the foregoing is true and correct. Signed this _______________ day of ___________________, 20 ______. _________________________________ Plaintiff’s Signature ORDER AND NOW, this _____________________day of _____________________, 20______, Motion granted. _____________________________________________________ UNITED STATES DISTRICT JUDGE American LegalNet, Inc. www.USCourtForms.com