Affidavit And Authorization To Withdraw From Inmate Account Form - United States District Court For The Northern District Of Georgia
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1
2UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF GEORGIA
:
AFFIDAVIT IN SUPPORT OF
_________________________
:
REQUEST TO PROCEED
Plaintiff/Petitioner,
:
IN FORMA PAUPERIS; AUTHORIZED
:
WITHDRAWAL FORM; CERTIFIED
v.
:
AFFIDAVIT OF INMATE ACCOUNT
STATUS.
_______________________________
Defendant/Respondent.
AFFIDAVIT AND AUTHORIZATION
FOR WITHDRAWAL FROM INMATE ACCOUNT
I, ___________________________, being first duly sworn or under penalty of perjury, affirm and
say that I am the plaintiff/petitioner in the above-styled action; that in support of my motion to proceed
without prepayment of fees or costs or give security therefor pursuant to Title 28 U.S.C.§ 1915 (a)(1), I
state that because of my poverty I am unable to pay the costs of said proceeding or to give security
therfor.
I further swear or affirm that the responses which I have made to the questions below are true.
1.
Are you presently employed? Yes ( )
No ()
a.
If employed, state the amount of your salary or wages per month and give the address of
your employer.___________________________________________________________
_______________________________________________________________________
b.
If you are not currently employed, state the date of your last employment and the
amount of salary or wages received.
_______________________________________________________________________
2.
Have you received within the past twelve months any money from any of the following sources?
a. Business, profession or self-employment?
Yes( ) No( )
b. Rent, payments, interest or dividends?
Yes( ) No( )
c. Pensions, annuities or life insurance?
Yes( ) No( )
d. Gifts or inheritances?
Yes( ) No( )
e. Any other source?
Yes( ) No( )
If you answered yes to any of the above, describe each source and state the amount received
from each._____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3.
Do you own any cash, or do you have money in a checking or savings account? (Include funds in
prison account.)
Yes ( ) NO ( ) If the answer is yes, state the total value of items owned.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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