UNITED STATES DISTRICT COURT WESTERN DISTRICT OF WISCONSIN ______________________________________ Full name of plaintiff(s) or petitioner(s) Case No. _______________________ (Provided by the clerk of court) v. ______________________________________ Full name of defendant(s) or respondent(s) PETITION AND AFFIDAVIT TO PROCEED WITHOUT PREPAYMENT OF FEES AND/OR COSTS I, ____________________________________________, declare that I am the plaintiff or petitioner in the above-named action. In support of my request to proceed in forma pauperis, I declare that I am unable to pay the fees and/or costs of these proceedings and that I am entitled to the relief sought in the complaint/petition/motion. I answer the following questions truthfully and under penalty of perjury (additional pages may be added, if necessary, to provide complete information): I. Personal Information 1) Are you currently incarcerated? Yes No If “No,” go to question 2. Complete all sections. If “Yes,” answer questions (a), (b) & (c), skip to Section IV. Complete sections IV and V. (a) State the place of your incarceration and provide your prisoner identification number: _______________________________________ (place) (b) Are you employed at the institution? (c) Do you receive any payment from the institution? _____________________________ (number) Yes No Yes No If you are a prisoner, attach a printout of your prison trust account statement showing transactions for the six-month period immediately preceding the filing of your complaint, motion, or petition and showing the balance of your release account. Prisoners who are permitted to file in forma pauperis must pay the full filing fee in installments. American LegalNet, Inc. www.FormsWorkflow.com (WIWD 12/07) Personal Information - continued 2) Are you employed? Yes No 3) Are you currently married? If “Yes,” is your spouse employed? Yes Yes No No 4) Do you have any legal dependents (children/adults) whom you are responsible for supporting? Yes No If “Yes,” list them below: First and Last Initials (For Minor Children Only) or Name Relationship to You Age Amount of Support Provided Per Month ______________________________ _________________ ________ $____________ ______________________________ _________________ ________ $____________ ______________________________ _________________ ________ $____________ II. Income - If you are married, your answers must include your spouse's income. (When calculating income, you must include any salary, child support, public assistance, unemployment compensation, disability payments, life insurance payments, pensions, annuities, workers' compensation, stock dividends and interest, gifts, and inheritance, or other incoming monies.) State your total monthly income? $ ______________ Provide the name of your employer(s): _______________________________________ State your spouse's total monthly income? $ ______________ State the amount of money you have received from any other source in the last twelve months (e.g., rent payments, pension or insurance payments, gifts, inheritance, disability or workers’ compensation payments). Please attach an additional sheet if necessary. Source of income Amount ______________________________________________ $ ______________________ ______________________________________________ $ ______________________ American LegalNet, Inc. www.FormsWorkflow.com III. Expenses - If you are married and/or have dependents, your expenses should also include your household's expenses. (When calculating household expenses, you may include groceries, clothing, medical costs, utilities which are not included in your rental payments, transportation, and insurance.) 1) Identify the following amounts that you pay per month: Rent or Mortgage $ __________________________________ Car payment(s) $ __________________________________ Alimony and/or court-ordered child support $ __________________________________ Credit card payment(s) $ __________________________________ 2) Do you have any other monthly expenses that you have not already identified? Yes No If “Yes,” list them below: Expense Amount __________________________________ $ __________________________________ __________________________________ $ __________________________________ __________________________________ $ __________________________________ 3) What is the total amount of your 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 residence(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 residence(s)? $ ____________________ American LegalNet, Inc. www.FormsWorkflow.com IV. Property - continued 3) Do you own any other valuable tangible property, including but not limited to, jewelry, artwork, or antiques? Yes No If “Yes,” identify the property and approximate value(s). Property Approximate Value ________________________________________________ $______________________ ________________________________________________ $______________________ ________________________________________________ $______________________ 4) Do you have any cash or checking, savings, or other similar accounts? Yes No If “Yes,” state the total amount of such sums. $ ____________________________________ 5) Do you own any intangible property, including but not limited to real estate, stocks, bonds, trusts, or individual retirement accounts (e.g., IRA, 401 k)? Yes No If “Yes,” state the nature of that property and approximate value(s). ____________________________________________________________________________ V. Other Circumstances - Describe any other financial circumstance(s) that you would like the court to consider when reviewing this petition. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ___________________________ Date _________________________________________ Signature - Signed Under Penalty of Perjury American LegalNet, Inc. www.FormsWorkflow.com