Motion Affidavit To Proceed In Forma Pauperis Without Prepayment Of Fees
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1
2UNITED STATES DISTRICT COURT
DISTRICT OF NEW HAMPSHIRE
_____________________________________
Plaintiff
v.
Civil Action No. _______________________________
_____________________________________
Defendant(s)
MOTION/AFFIDAVIT TO PROCEED IN FORMA PAUPERIS
WITHOUT PREPAYMENT OF FEES
I, ______________________________________________, declare that I am the plaintiff/petitioner/movant in
the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 U.S.C. §1915, I declare that I am unable to pay the costs of these proceedings and that I am entitled
to relief. In support of this application, I answer the following questions under penalty of perjury:
1.
Are you currently incarcerated?
[ ] Yes
[ ] No
(If "No" go to Question 2)
Name of Institution:
________________________________________________________________________
Are you employed at the institution?
[ ] Yes
[ ] No
If "Yes" - do you receive any payment from the institution?
[ ] Yes
[ ] No
If "Yes" - how much per month? $______________
You must attach a Certificate of Custodial Institution (USDCNH-14) completed by the institution of your
incarceration. The institution will also supply a copy of your trust account statement for the preceding
six months. Processing of your case will be delayed if this material is not attached.
2.
Are you currently employed? (Skip this question if incarcerated)
[ ] Yes
[ ] No
a.
If the answer is "Yes" - state the amount of your take-home salary or wages and pay period (i.e.
per week, month, etc.) and give the name and address of your employer.
b.
If the answer is "No" - state the date of your last employment, the amount of your take-home
salary or wages and pay period (i.e. per week, month, etc.) and the name and address of your
last employer.
3.
In the past twelve months, have you received any money from any of the following sources?
a.
Business, profession or other self-employment
[ ] Yes
[ ] No
b.
Rent payments, interest or dividends
[ ] Yes
[ ] No
c.
Pensions, annuities or life insurance payments
[ ] Yes
[ ] No
d.
Disability or worker's compensation payments
[ ] Yes
[ ] No
e.
Gifts or inheritances
[ ] Yes
[ ] No
f.
Any other sources
[ ] Yes
[ ] No
If the answer to any of the above is "Yes" - describe each source of money and state the amount
received and what you expect you will continue to receive.
(continued on reverse)
USDCNH-13 (11-04) (Previous Editions Obsolete)
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