Affidavit In Support Of Request To Proceed In Forma Pauperis Page 2

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If you answered “Married”:
A.
(1)
Is your spouse employed?
Yes______
No______
If “Yes”: how much does your spouse earn each month?
_____________________________________________________
III.
Do you have any dependents?
Yes______No______
If you answered “Yes,” list each dependent's name, age and their relationship to
A.
you:
Name
Age
Relationship
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
IV.
Within the past twelve (12) months, have you received any income from a business,
profession or other form of self-employment, or in the form of rent payments, interest
dividends, retirement benefits, annuity payments or any other source, including Workers
Compensation, Social Security payments, disability payments?
Yes______No______
If you answered “Yes,” describe each source of income and the total amount you
A.
received from that source over the twelve-month period:
Source
Amount
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
V.
Do you or your spouse have any cash on hand or money in a savings, checking or other
account?
Yes______No______
If you answered “Yes,” state the combined total amount:
A.
$________________________
VI.
Do you or your spouse own any real estate, stocks, bonds, notes, automobiles or any
other valuable property?
Yes______
No______
If you answered “Yes,” describe each piece of property and state its value:
A.
Appendix
Page 3

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