UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF TEXAS § § § § § § § Petitioner vs. Respondent(s) I, DECLARATION IN SUPPORT OF REQUEST FOR THE COURT TO APPOINT COUNSEL , declare that I am the petitioner in the above entitled case; that in support of my motion for the Court to appoint counsel, I state that because of my poverty, I am unable to retain the services of counsel by payment of fees or on a contingency basis, therefore I believe I am entitled to relief. 1. Are you presently employed? Yes No If you answered YES, state the amount of your salary or wages per month, and give the name and address of your employer. If you answered NO, state the date of last employment and the amount of the salary and wages per month which you received. CONTINUED ON NEXT PAGE American LegalNet, Inc. www.FormsWorkflow.com 2. Have you received, within the past 12 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? e. Any other sources? Yes Yes No 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. 3. Do you own cash, or do you have money in a checking or savings account? Yes No If you answered YES, state the total value of the items owned. 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property, excluding ordinary household furnishings and clothing? Yes No If you answered YES, describe the property and state its approximate value. 2 CONTINUED ON NEXT PAGE American LegalNet, Inc. www.FormsWorkflow.com 5. List the persons who are dependent upon you for support, state your relationship to those persons (father, mother, spouse, etc.) and indicate how much you contribute toward their support. List only initials, not full names, of minor children. I, declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed on: Signature of Petitioner 3 American LegalNet, Inc. www.FormsWorkflow.com