Application To Proceed In Forma Pauperis Relating To Page 3

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CONFIDENTIAL
The following represents a list of my assets and their value.
Value
Loan Balance
Car
____________________
$__________
$__________
(Year and type of car)
Mobile Home,
House, or
Other Real Estate
____________________
$__________
$__________
(Size, type,
and/or year of home)
Bank Accounts
_____________________
$__________
$__________
(Name of bank
and type of account)
Other
_____________________
$__________
$__________
_____________________
$__________
$__________
_____________________
$__________
$__________
My total monthly expenses are:
Rent
$_____________________
Phone, Gas, Electricity, and Other Utilities $_____________________
Food
$_____________________
Child Care
$_____________________
Insurance
$_____________________
Medical
$_____________________
Transportation
$_____________________
Other
$_____________________
______________________
______________________
(List other expenses)
TOTAL MONTHLY EXPENSES............................$______________________
(Total from above lines)
___________________________________
AFFIANT (your signature)
3

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