UNITED STATES DISTRI CT COURTS EASTERN DIS TRIC T OF TEX AS _______________ DIVISION _________________________________ plaintiff vs Case No. _______________________________________________________ defendant MOTION TO PROCEED IN FORMA PAUPERIS Plaintiff, ____________________________________________, respectfully moves thisHonorable Court for leave to proceed in this matter without payment of fees, costs, or security.Attached hereto is an affidavit in support of my motion to proceed in forma pauperis. Respectfully submitted, Plaintiff ____________________________ Address ____________________________ ____________________________ ____________________________ Telephone___________________________>>>> 2Date_____________________________ AFFIDAVIT IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERISINSTRUCTIONS: Complete all questions in this affidavit and then sign it. Do not leave anyblanks. If the answer to a question is 0", none, or not applicable (NA), write in thatresponse. If you need more space to answer a question or to explain your answer, attach aseparate sheet of paper identified with your name, your cases docket number, and the questionnumber 1. Are you presently employed: YES ____NO ____ (a) If the answer is YES, state the amount of your gross salary or wages per month and give the name and address of your employer. $ ________________ per month Employer________________________________________________________________ ________________________________________________________________________ (b) If the answer is NO, state the date of last employment and the amount of the gross salary and wages per month which you received. $_________________ per month Employer________________________________________________________________ ________________________________________________________________________2. Is your spouse presently employed: YES ____NO ____ If the answer is YES, state the gross amount of his/her salary or wages per month and give the name and address of his/her employer. $_______________ per month Employer _______________________________________________________________3. Have you or your spouse received within the past twelve (12) months any money from any of the following sources: >>>> 3 (a) Business, profession, or form of self-employment? YES ____ NO____ (b) Rent payments, interest or dividends? YES ____ NO ____ (c) Pensions, annuities, or life insurance payment? YES ____ NO ____ (d) Gifts or inheritances? YES ____ NO ____ (e) Any other sources? YES ____ NO ____ If the answer to any of the above questions is YES, describe each source of money and state the amount received from each during the last twelve (12) months and by whom. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________4. How much cash do you and your spouse have? $_________________.5. List any money you or your spouse have in bank accounts or in any other financial institution and the name of the financial institution. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________6. List the assets and the values, which you or your spouse own. Do not list clothing and ordinary household furnishings. Home Address ___________________________________________________________ Value of Home ___________________________________________________________ Motor Vehicle #1 Make, year, model ________________________________________________________>>>> 4 Value of motor vehicle #1 __________________________________________________ Motor Vehicle #2 Make, year, model ________________________________________________________ Value of motor vehicle #2 __________________________________________________7. Do you or your spouse own any other real estate, stocks, bonds, notes, automobiles, or other valuable property not listed above (excluding ordinary household furnishings and clothing)? YES ____ NO ______ If the answer is YES, describe the property and state its approximate value. ________________________________________________________________________ ________________________________________________________________________8. List the persons who are dependent upon you or your spouse for support, state your relationship to those persons, and indicate how much you contribute toward their support _______________________________________________________________________ _______________________________________________________________________9. Do you expect any major changes to your or your spouses monthly income or expenses or in your or your spouses assets or liabilities during the next 12 months?. YES _____ NO _____ If yes, describe below or on an attached sheet. ________________________________________________________________________ ________________________________________________________________________10. Estimate the average monthly expenses of you and your family. If different, list separately the amounts paid by your spouse. Rent or home-mortgage payment ____________________________________________ Utilities (electricity, heating fuel, water, sewer and telephone) _____________________ Home maintenance (repairs and upkeep) ______________________________________>>>> 5Food ___________________________________________________________________Clothing ________________________________________________________________Laundry and dry-cleaning __________________________________________________Medical and dental expenses ________________________________________________Transportation (not including motor vehicle payments)___________________________Recreation, entertainment, newspapers, magazines, etc. ___________________________Insurance (not deducted from wages or included in mortgage payments) Homeowners or renters insurance _____________________________________ Life insurance _____________________________________________________ Health insurance ___________________________________________________ Motor vehicle insurance _____________________________________________ Other insurance ____________________________________________________Taxes (not deducted from wages or included in mortgage payments) ___________Ins