UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF TEXAS Plaintiff v. Defendant DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS I, , declare, depose, and say that I am the plaintiff in the above entitled case; that 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 the costs of said proceeding or to give security therefor, that 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. Are you presently employeed? Yes No a. If you answered YES, state the amount of your salary or wages per month, and give the name and address of your employer. b. If you answered NO, state the date of last employment and the amount of the salary and wages per month which you received. 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? Yes No e. Any other sources? Yes 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. American LegalNet, Inc. www.FormsWorkflow.com 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. 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 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). Date: Signature of Plaintiff American LegalNet, Inc. www.FormsWorkflow.com