Affidavit In Support Of Request To Proceed In Forma Pauperis (Page 2 of 3) in pdf

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

If you answered “Married”:

(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

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

received from that source over the twelve-month period:

Source

Amount

______________________________________________________

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:

$________________________

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:

Appendix

Page 3

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