Application To Proceed In Forma Pauperis - United States Court Of Federal Claims Page 2
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23. Within the past twelve (12) months, have you received any money from the following sources?
□
□
a. Business, profession, or other form of self-employment?
Yes
No
□
□
b. Rent payments, interest, or dividends?
Yes
No
□
□
c. Pensions, annuities, or life insurance payments?
Yes
No
□
□
d. Gifts or inheritances?
Yes
No
□
□
e. Any other sources?
Yes
No
If the answer to any of the above is yes, describe each source of money and the amount
received in the last twelve (12) months, and what you expect to receive in the future.
If the answer is no to all of the questions above, explain how you are paying your expenses.
4. How much money do you have in cash or in a checking, savings, or inmate account?
5. Do you own any automobiles, real estate, stocks, bonds, securities, trusts, jewelry, art work, or
other financial instruments or items of value, including any items of value held in someone else’s
name? If so, describe each property and its approximate value.
6. Do you have any housing, transportation, utilities, or loan payments, or other regular monthly
expenses? If so, describe and provide the amount of each monthly expense.
7. List any persons dependent upon you for support, your relationship to those persons, and how
much you contribute toward their support.
8. Do you have any debts or financial obligations not described above? If so, describe the amounts
owed and to whom they are payable.
Affidavit: I declare under penalty of perjury that the foregoing is true and correct and that a false
statement may result in dismissal of my complaint.
________________________________________
_______________________________________
(Date)
(Signature of Applicant)
____________________________________
_______________________________________
Prison Identification # (if incarcerated)
Print Name (Last, First, MI)
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