COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. IN THE UNITED STATES DISTRICT COURT EASTERN DISTRICT OF TENNESSEE : Plaintiff(s) -against- ) ) ) ) ) ) v. JUDICIAL SUBPOENA : : NO. (To be assigned by the Clerk’s : Office. Do not write in this blank.) Defendant(s) : ...................................................... APPLICATION TO PROCEED IN FORMA PAUPERIS WITH SUPPORTING DOCUMENTATION THE PEOPLE OF THE STATE OF NEW YORK I, , declare that I am the: TO petitioner/plaintiff movant (filing 28 U.S.C. § 2255 motion) respondent/defendant other GREETINGS: in the above-referenced proceeding. In support of my request to proceed without being required to prepay fees or give security therefor, WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before I state that because of my poverty, I am unable to pay the fees for this action or give security therefor. I believe that I am entitled to the the Honorable at the Court relief sought in my complaint/petition. The nature of my action, defense, or other proceeding or the issues that I intend to present are , located at County of briefly stated as follows: in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party of whose behalf I answer the following questions: In further supporton this application,this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. YOUR EMPLOYMENT AND INCOME DATA Witness, Honorable Middle Court in County, 1. NAME (First Last) day of 3. SOCIAL SECURITY NO. - , one of the Justices of the , 20 2. BIRTH DATE (mo day yr) 4. TELEPHONE NOS. (Attorney must sign above and type name below) 5. PRISONER NUMBER: 7. HOW LONG AT CURRENT HOME ADDRESS? 6. HOME ADDRESS? Attorney(s) for 8. OWN OR RENT? STREET: APT. NO.: CITY: Office and P.O. Address STATE: ZIP CODE: Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 9. CURRENT EMPLOYER (Including employment at the penal facility) STREET: Plaintiff(s) -against- Index No. : Calendar No. : JUDICIAL SUBPOENA : CITY: STATE: : ZIP CODE: 10. HOW LONG AT CURRENT EMPLOYMENT? : 11. OCCUPATION (Describe what you do): Defendant(s) : ...................................................... 12. IF EMPLOYED, STATE BOTH THE GROSS AND NET AMOUNTS OF YOUR SALARY AND WAGES PER MONTH. GROSS: NET: 13. IF NOT CURRENTLY EMPLOYED, GIVE MONTH AND YEAR OF LAST EMPLOYMENT THE PEOPLE OF THE STATE OF NEW YORK 14. HOW MUCH DID YOU EARN PER MONTH AT YOUR LAST EMPLOYMENT? TO 15. HAVE YOU RECEIVED ANY MONEY FROM ANY OF THE FOLLOWING SOURCES WITHIN THE PAST TWELVE MONTHS? a. GREETINGS: Business, professional or other form of self-employment? Yes No WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court If YES, state County of the source and amount:located at in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the b. Rent payments, interest, or dividends? Yes No Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to If YES, state the source and amount: the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. c. Pensions, annuities, or life insurance payments? Yes Court in Witness, Honorable No County, , one of the Justices of the day of , 20 If YES, state the source and amount: (Attorney must sign above and type name below) d. Gifts or inheritance: Yes No Attorney(s) for If YES, state the source and amount e. Any other sources? Yes Office and P.O. Address No If YES, state the source and amount 2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : ASSETS: Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : LIST ANY OF THE FOLLOWING ASSETS THAT YOU OWN AND THE TOTAL AMOUNT: : 1. CASH 2. CHECKING ACCOUNTS--TOTAL BALANCE (List Banks Below) _________________________________ $ : $ Defendant(s) : ...................................................... _________________________________ _________________________________ THE PEOPLE OF THE STATE OF NEW YORK 3. SAVINGS ACCOUNTS--TOTAL BALANCE (List Banks Below) _________________________________ $ TO _________________________________ _________________________________ GREETINGS: 4. STOCKS AND BONDS $ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the ESTATE--CURRENT FAIR MARKET VALUE (List the at Locations Below) Court 5. REAL Honorable located at County of $ in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the $ $ 6. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to TOTAL REAL maximum $ the party on whose behalf this subpoena was issued for a ESTATE penalty of $50 and all damages sustained as a result of your failure to comply. VALUE OF PERSONAL PROPERTY, EXCLUDING VEHICLES (Itemize) Witness, Honorable Court in County, $ , one of the Justices of the day of , 20 $ $ (Attorney must sign above and type name below) $ Attorney(s) for TOTAL PERSONAL PROPERTY $ Office and P.O. Address 3 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 7. : License No. Plaintiff(s) -against- Calendar No. : MOTOR VEHICLES Year/Make Index No. Current Value JUDICIAL SUBPOENA : $ : $ : $ Defendant(s) : TOTAL VALUE OF MOTOR VEHICLES ...................................................... 8. $ DEBTS OWED TO YOU (List Name of Debtor) $ THE PEOPLE OF THE STATE OF NEW YORK $ TO TOTAL DEBTS OWED TO YOU 9. $ GREETINGS: OTHER ASSETS (ITEMIZE) $ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court $ located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed $ or adjourned date, to testify and give evidence as a witness in this action on the part of the TOTAL OTHER ASSETS $ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. TOTAL ASSETS Witness, Honorable Court in County, $ , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address 4 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : LIABILITIES: Plaintiff(s) 1. -against- Calendar No. : JUDICIAL SUBPOENA : NOTES (LOANS) PAYABLE TO BANKS (List Banks and Amount of Loans) : $ : $ Defendant(s) : ...................................................... $ TOTAL LOANS PAYABLE TO BANKS $ THE PEOPLE OF THE STATE OF NEW YORK 2. NOTES (LOANS) PAYABLE TO OTHERS $ 3. MORTGAGES PAYABLE ON REAL ESTATE $ 4. CREDIT CARDS AND ACCOUNTS PAYABLE TO CREDITORS $ 5. GREETINGS: MEDICAL BILLS $ 6. WE COMMAND YOU, that TAXES AND ASSESSMENTS PAYABLE all business and excuses being laid aside, you and each of you attend before $ 7. County of OTHER LIABILITIES (Itemize) TO , at the Court located at in room , on the day of , 20 , at o'clock in the noon, and at any recessed $ or adjourned date, to testify and give evidence as a witness in this action on the part of the the Honorable $ $ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. TOTAL LIABILITIES Witness, Honorable Court in County, $ day of , one of the Justices of the , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address 5 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : LIVING EXPENSES: : : Plaintiff(s) Index No. Calendar No. JUDICIAL SUBPOENA *TO BE COMPLETED BY PRISONERS WHO HAVE BEEN RELEASED, BUT REMAIN ON PAROLE OR PROBATION OR ANY -against: OTHER TYPE OF RELEASE PROGRAM. SEE 28 U.S.C. § 1915(c). : Monthly Payment RENT or MORTGAGE PAYMENT (Indicate Which) $ : UTILITIES Defendant(s) $ : a. Electricity . .b. . . . . . Water. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$. . . . . .... c. Gas $ d. Telephone $ e. Other $ Balance Owing $ $ $ $ $ $ THE PEOPLE OF THE STATE OF NEW YORK FOOD $ $ TO ALIMONY $ $ CHILD SUPPORT $ $ CHILD CARE $ $ SCHOOL EXPENSES $ $ AUTOMOBILE NOTE $ $ GREETINGS: AUTOMOBILE INSURANCE $ $ AUTOMOBILE REPAIRS $ being laid aside, you and each of you attend before $ WE COMMAND YOU, that all business and excuses GASOLINE $ $ , the Honorable at the Court FURNITURE NOTE $ $ located at County of CLOTHING $ $ in room , on the day of , 20 , at o'clock in the noon, and at any recessed CABLE TELEVISION $ $ or adjourned this LIFE INSURANCE date, to testify and give evidence as a witness in $ action on the part of the $ HOSPITALIZATION INSURANCE $ $ DOCTORS $ $ DRUGS $ $ CREDIT CARDSYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to (LIST/MONTHLY PAYMENTS) the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. $ $ Witness, Honorable Court in County, $ $ day of , 20 OTHER CHARGE ACCOUNTS OR CREDITORS TAXES ANY OTHER DEBTS (LIST) $ $ , one of the Justices of the $ $ $ $ (Attorney must sign above and type name below) $ $ $ $ Attorney(s) for TOTAL EXPENSES $ $ $ $ $ Office and P.O. Address 6 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : SPOUSE’S EMPLOYMENT AND INCOMECalendar No. DATA 1. NAME (First Middle Last) Plaintiff(s) : 2. BIRTH DATE (mo day yr) JUDICIAL SUBPOENA -against- : 3. SOCIAL SECURITY NO. - 4. TELEPHONE NOS. 5. HOME ADDRESS (if different from yours) 6. HOW LONG AT CURRENT HOME ADDRESS? : : Defendant(s) 7. OWN OR RENT? : ...................................................... STREET: APT. NO.: CITY: STATE: THE PEOPLE OF THE STATE OF NEW YORK ZIP CODE: 8. CURRENT EMPLOYER: 9. HOW LONG AT CURRENT EMPLOYMENT? TO STREET: CITY: STATE: ZIP CODE: GREETINGS: 10. OCCUPATION (Describe what spouse does): WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , at the Court located at County of Salary of Wages $ in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness$in this action on the part of the Commissions 11. SPOUSE’S CURRENT MONTHLY INCOME: the Honorable All Other Sources (Pensions; Soc. Sec.; Rent; Interest; Dividends; Alimony; etc...): $ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. TOTAL $ Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address 7 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar NAME OF DEPENDENTS AND INCOME (if any) No. Names: -against- Age: Plaintiff(s) : Relationship: JUDICIAL SUBPOENA Living With Whom? : : : Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO TOTAL MONTHLY INCOME OF DEPENDENTS INCLUDING CHILD SUPPORT PAYMENTS (exclude spouse) $ TOTAL MONTHLY INCOME OF APPLICANT, SPOUSE, AND DEPENDENTS GREETINGS: $ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address 8 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Calendar I declare under penalty of perjury that the above information is true :and correct. No. : Plaintiff(s) -against- JUDICIAL SUBPOENA : : (Date) (Signature of Applicant) : Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK CERTIFICATE TO TO BE COMPLETED BY AN AUTHORIZED CUSTODIAN OF INMATE ACCOUNTS GREETINGS: I certify that the applicant herein has the sum of $ on account to his/her credit at the (institution where the applicant is currently incarcerated). I further certify that the WE COMMAND in the applicant’s trustand excuses being laid aside, you and each of you attend before average balance YOU, that all business fund account during the last six months was the Honorable copy of the applicant’s trust fund account (or an institutional equivalent) for the last six months , at the Court $ . A located at County of is attached hereto. in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and Officer) (Signature of Authorized all damages sustained as a result of your failure to comply. Witness, Honorable Sworn and subscribed before me this Court day of in , 20 County, . , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Notary Public My commission expires: Attorney(s) for Office and P.O. Address 9 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com