ATTACHMENT 4 - Application to Proceed In Forma Pauperis United States District Court for the Western District of Texas ______________Division (Name of plaintiff or plaintiffs) Civil Action Number: v. (Case Number to be supplied by the Intake Clerk) (Name of defendant or defendants) APPLICATION TO PROCEED IN FORMA PAUPERIS I, , declare that I am the Plaintiff in the above-entitled proceeding; that, in support of my request 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 give security therefor; that 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. 1. Are you presently employed? a. [ ] Yes [ ] No If the answer is "yes," state the amount of your salary or wages per month, and give the name and address of your employer: Employer: Salary/Wages per Month: Position: 31 American LegalNet, Inc. www.USCourtForms.com Dates of Employment: b. If the answer is "no," state the date of last employment, amount of your salary or wages per month, and name and address of your former employer: Employer: Salary/Wages per Month: Position: Dates of Employment: 2. Are you married? a. [ ] Yes [ ] No If the answer is "yes," state the amount of your spouse's salary or wages per month, and give the name and address of his/her employer: Employer: Salary/Wages per Month: Position: Dates of Employment: b. 3. If the answer is "yes," is your spouse dependent on your financial support? [ ] Yes [ ] No Do you have any children? [ ] Yes [ ] No a. b. 4. If the answer is "yes," state all of your children's names and their ages below: If the answer is "yes," are the children dependent on your financial support? [ ] Yes [ ] No List any other persons other than your spouse (if any) and your children (if any) who are dependent on your financial support (please state your relationship to them and how much you contribute toward their support): 32 American LegalNet, Inc. www.USCourtForms.com 5. Have you received within the past twelve months any money from any of the following sources? a. Business, profession or other form of self employment b. Rent payments, interest or dividends c. Pensions, annuities or life insurance payments d. Gifts or inheritances e. Family and/or Friends f. Any other sources [ [ [ [ [ [ ] ] ] ] ] ] Yes Yes Yes Yes Yes Yes [ [ [ [ [ [ ] ] ] ] ] ] No No No No No No 6. If the answer to any of the above is "yes," describe each source of money and state the amount received from each during the past twelve months. 7. Do you own any cash, or do you have money in checking or savings accounts? [ ] Yes [ ] No If the answer is "yes," state the total value of the items owned: 8. Do you own or have any interest in any real estate, stocks, bonds, notes, automobiles or other valuable property (excluding ordinary household furnishings and clothing)? [ ] Yes [ ] No If the answer is "yes," describe the property, state its approximate value, whether you have any outstanding mortgages, liens or debts secured by that property and, if so, the unpaid balance of that debt. 33 American LegalNet, Inc. www.USCourtForms.com 9. List all expenses and state the total amount of expenses, of any and all kinds, which you paid during the past six months. PLEASE BE SPECIFIC. 10. List any SPECIFIC exceptional reasons or circumstances that you feel entitle you to proceed in forma pauperis and/or that entitle you to be represented by a court appointed attorney. I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Date Signature of Plaintiff 34 American LegalNet, Inc. www.USCourtForms.com