WAWD (Rev. 12/11) IFP and Written Consent UNITED STATES DISTRICT COURT Western District of Washington Case Number: Plaintiff vs. DECLARATION AND APPLICATION TO PROCEED IN FORMA PAUPERIS AND WRITTEN CONSENT FOR PAYMENT OF COSTS DECLARATION AND APPLICATION TO PROCEED IN FORMA PAUPERIS Defendant(s) declare I am the plaintiff in this case; I believe I am entitled to relief; and I am unable to pay the costs of this proceeding or give security therefor. The nature of my action is briefly stated as follows: In support of this application, I answer all of the following questions: 1. Are you presently employed? Yes Total amount of net monthly salary (take home pay) $ Name and address of employer No Date of last employment Total amount of last net monthly salary $ Not married I (print your name) 2. If married, is your spouse presently employed? Yes Total amount of spouse's net monthly salary (take home pay) $ Name and address of employer No Date of spouse's last employment Total amount of last net monthly salary $ 3. For the past twelve months, list the amount of money you and/or your spouse have received from any of the following sources. a. Business, profession or other self-employment b. Income from rent, interest or dividends c. d. e. f. g. Pensions, annuities or life insurance payments Disability, unemployment, workers compensation or public assistance Gifts or inheritances Money received from child support or alimony Describe any other source of income $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Page of 4. List the amount for each of the following for you and/or your spouse: Cash on hand $ Checking Account $ Savings Account $ 5. Do you and/or your spouse own or have any interest in any real estate, stocks, bonds, notes, retirement plans, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? If Yes, describe the property and state its approximate value: Yes $ No 6. Are any persons dependent upon you or your spouse for support? If Yes, state their relationship to you or your spouse, and indicate how much is contributed toward their support each month. (Do not include names of minor children. ) Yes $ No 7. Describe the types of monthly expenses you incur, such as housing, transportation, utilities, loan payments, or other regular monthly expenses and the amount spent each month. $ 8. Provide any other information that will help explain why you cannot pay court fees and costs. I declare under penalty of perjury that the foregoing is true and correct. Executed on: (Date) Signature of Plaintiff WRITTEN CONSENT FOR PAYMENT OF COSTS UNDER LOCAL RULE CR3(b) I, (print your name) hereby consent that any recovery in damages that I may receive in the above-captioned cause may be reduced, if so directed by the court, in such an amount as is necessary for payment of the unpaid fees and costs which are taxed against me in the course of this litigation. Executed on: (Date) Signature of Plaintiff Page of American LegalNet, Inc. www.FormsWorkFlow.com