UNITED STATES DISTRICT COURT EASTERN DISTRICT OF WISCONSIN ________________________________ Full name of plaintiff(s) v. Case No. ___________________________ (Provided by the Clerk of Court) ________________________________ Full name of defendant(s) NONPRISONER REQUEST TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING THE FILING FEE Answer the following questions to the best of your ability. Note: If you do not tell the truth, the Court may dismiss your lawsuit. I. Personal Information 1) Are you employed? Yes No 2) Are you married? Yes No If "Yes," is your spouse employed? Yes No 3) Do you have any dependents that you are responsible for supporting? Yes No If "Yes," list them below: Name or initials (for Relationship to You Age Amount of Support minor children only) Provided per Month ________________________ _________________ ________ $ ____________ ________________________ _________________ ________ $ ____________ ________________________ _________________ ________ $ ____________ Fee Request ­ 1 American LegalNet, Inc. www.FormsWorkFlow.com II. Income ­ If you are married, your answers must include your spouse's income. (When calculating income, include any wages, salary, rent, child support, public assistance, unemployment compensation, disability payments, life insurance payments, pensions, annuities, workers compensation, stock dividends and interest, gifts and inheritance, or other money you receive from any source.) 1) State your total monthly wages or salary? $ ______________ 2) Provide the name and address of your employer(s): ______________________________________________________________ 3) State your spouse's total monthly wages or salary? $ ______________ State the amount of money you have received from any other source in the last twelve months, such as the sources listed above. Please attach an additional sheet if necessary. Amount Source of income ______________________________________________ $ ______________________ ______________________________________________ $ ______________________ III. Expenses ­ If you are married or have dependents, your expenses should also include your household's expenses. 1) Identify the following amounts that you pay per month: Rent or Mortgage $ __________________________________ Car payment(s) $ __________________________________ Alimony or courtordered child support $ __________________________________ Credit card payment(s) $ __________________________________ Other household expenses $ __________________________________ (e.g., groceries, clothing, medical costs, utilities, cell phone, internet, etc.) Fee Request ­ 2 American LegalNet, Inc. www.FormsWorkFlow.com 2) Do you have any other monthly expenses that you have not already listed? Yes No If "Yes," list them below: Expense Amount ____________________________ $ __________________________________ ____________________________ $ __________________________________ ____________________________ $ __________________________________ 3) What are your total monthly expenses? $ __________________________________ IV. Property ­ If you are married, your answers must include your spouse's property. 1) Do you own a car? Yes No If "Yes," list car(s) below: Make and Model Year Approximate Current Value _______________________________________________ __________ $ ________________ _______________________________________________ __________ $ ________________ 2) Do you own your home(s)? Yes No If "Yes," state the approximate value(s). $ ____________________ What is the amount of equity (assessed value of residence minus outstanding mortgage balance) in the home(s)? $ ____________________ 3) Do you have any cash or checking, savings, or other similar accounts? Yes No If "Yes," state the total of such sums. $ _____________________________ Fee Request ­ 3 American LegalNet, Inc. www.FormsWorkFlow.com 4) V. Do you own any other property of value, such as real estate, stocks, bonds, trusts, or individual retirement accounts (e.g., IRA, 401 k), artwork, or jewelry? Yes No If "Yes," describe the property and the approximate value(s). ________________________________________________________________ Other Circumstances ­ Describe any other financial circumstance(s) that you would like the Court to consider when reviewing this petition. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ I, ____________________, declare that I am the plaintiff bringing this complaint. I declare that I am unable to prepay the fee and that I am entitled to the relief sought in the complaint. I declare under penalty of perjury that the foregoing is true and correct. ___________________________ _________________________________________ Date Signature Fee Request ­ 4 American LegalNet, Inc. www.FormsWorkFlow.com