Reset all fields Print Form IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF TEXAS AUSTIN DIVISION � � � � � V. Case No. APPLICATION TO PROCEED IN FORMA PAUPERIS AND FINANCIAL AFFIDAVIT IN SUPPORT I, , declare that I am the Applicant in the above-entitled proceeding. I am requesting permission to proceed without being required to prepay fees, costs, or give security therefor. In support of my application, I state that because of my poverty, I am unable to pay the costs of said proceeding or give security therefor and I believe I am entitled to relief. The nature of my action is briefly stated as follows: In further support of this application, I answer the following questions: Applicant's Name: Applicant's Home Address: Questions Regarding Ability to Pay Employment: Are you now employed? Yes No Am Self Employed If yes, how much do you earn per month? $ 1 American LegalNet, Inc. www.FormsWorkFlow.com If no, give month and year of last employment How much did you earn per month? $ Name and Address of current or prior employer: If married, state Spouse's name: Is your Spouse employed? Yes No If working, how much does your spouse earn? $ Do you receive any funds from relatives or for child support? If so, how much per month do you receive? $ Other Income: Have you received within the past 12 months any income from a business, profession or other form of self-employment, or in the form of rent payments, interest, dividends, retirement or annuity payments (such as Social Security benefits), or other sources, including government benefits (such as A.F.D.C. or Social Security disability benefits)? If yes, give the amount and identify the sources: Received $ $ $ $ Sources Yes No 2 American LegalNet, Inc. www.FormsWorkFlow.com Cash: Have you any cash on hand or money in savings or checking accounts? Yes If yes, state total amount: $ If neither you nor your spouse receive income of any kind, how are you able to pay for food and shelter? No Property: Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes No If yes, give value and describe it and say in whose name the property is registered. Value $ $ $ $ Family Status and Dependents: Marital Status: Single Married Widowed Separated or Divorced Description Total Number of Dependents: Are any of your dependents employed? If so, where: How much do your dependent(s) earn monthly? $ 3 American LegalNet, Inc. www.FormsWorkFlow.com List persons you actually support, your relationship to them. Do you pay alimony or child support or any other court-ordered payments? Yes If yes, list how much and describe: No Monthly Debts of Applicant and/or Dependents Type of Debt Name of Creditor Total Debt $ $ $ $ Monthly Expenses of Applicant and/or Dependents Rent or House Payment: Electric & Water Bills: Gas: Phone: Insurance: For what purpose: $ $ $ $ $ Payment $ $ $ $ 4 American LegalNet, Inc. www.FormsWorkFlow.com Prescriptions: For what purpose: Transportation/Car Payments: For what purpose: Medical Bills: For what purpose: Legal Bills: For what purpose: Loans: For what purpose: Miscellaneous: For what purpose: $ $ $ $ $ $ Is there any more information the Court should consider in making its determination? 5 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF APPLICANT I declare under penalty of perjury the above answers and statements to be true and correct to the best of my knowledge. I understand that this affidavit will become an official part of the United States District Court files and that any false or dishonest answer or statements knowingly made by me in this Financial Affidavit are illegal and may subject me to criminal penalties, including any applicable fines or imprisonment, or both. Signature: Printed Name: Date: 6 American LegalNet, Inc. www.FormsWorkFlow.com