NDTX Rev. 7/14 IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF TEXAS _________________ DIVISION Plaintiff's Name and ID Number Place of Confinement CASE NO. v. (Clerk will assign the number) APPLICATION TO PROCEED IN FORMA PAUPERIS Defendant's Name and Address I, _____________________________________, declare, depose, and say that I am the Plaintiff in the above entitled case. In support of my motion to proceed without being required to prepay fees, costs or give security therefor, I state that because of my poverty, I am unable to pay in advance the filing fee for said proceedings or to give security for the filing fee. I believe I am entitled to relief. I further declare that the responses which I have made to questions and instructions below are true. 1. Have you received, within the past 12 months, any money from any of the following sources? a. b. c. d. e. f. Business, profession or form of self-employment? Rent payments, interest or dividends? Pensions, annuities or life insurance payments? Gifts or inheritances? Family or friends? Any other sources? 9 Yes 9 Yes 9 Yes 9 Yes 9 Yes 9 Yes 9 No 9 No 9 No 9 No 9 No 9 No If you answered YES to any of the questions above describe each source of money and state the amount received from each during the past 12 months. 2. Do you own cash, or do you have money in a checking or savings account, including any funds in prison accounts? 9 Yes 9 No If you answered YES, state the total value of the items owned. 1 American LegalNet, Inc. www.FormsWorkFlow.com 3. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property, excluding ordinary household furnishings and clothing? 9 Yes 9 No If you answered YES, describe the property and state its approximate value. I understand that a false statement or answer to any questions in this affidavit will subject me to penalties for perjury. I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct (28 U.S.C. � 1746). Signed this _________________day of ________________________, 20_________. __________________________________________________ Signature of Plaintiff ID Number YOU MUST ATTACH A CURRENT SIX (6) MONTH HISTORY OF YOUR INMATE TRUST ACCOUNT. YOU CAN ACQUIRE THE APPROPRIATE INMATE ACCOUNT CERTIFICATE FROM THE LAW LIBRARY AT YOUR PRISON UNIT (OR OTHER DESIGNATED LOCATION AT YOUR INSTITUTION). 2 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF INMATE TRUST ACCOUNT I, the undersigned authorized officer of the where (name of inmate) as a prisoner, do hereby certify that: (1) On this day the prisoner has in his account the sum of $ (2) During the past six months, the prisoner's: Average monthly balance was $ ___________________. Average monthly deposits to the prisoner's account were $ ___________________. Attached is a certified copy of the prisoner's trust account statement (or institutional equivalent) showing transactions for the past six months. Signed this _________________day of ________________________, 20_________. . (name of institution) , Inmate ID No. , is confined __________________________________________ Authorized Officer __________________________________________ Institution of Confinement Authorization I, the undersigned inmate, authorize the institution where I am incarcerated to withdraw and forward to the court any initial partial filing fee or appeal fee and any subsequent installments ordered by a Court under the in forma pauperis provisions of 28 U.S.C. � 1915. __________________________________________ Signature of Prisoner/Plaintiff/Appellant Inmate ID No. ___________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com