Motion Affidavit To Proceed In Forma Pauperis Without Prepayment Of Fees (Page 2 of 2) in pdf

Motion Affidavit To Proceed In Forma Pauperis Without Prepayment Of Fees Page 2

Do you have any cash or checking or savings accounts?

[ ] Yes

[ ] No

If "Yes" - state the total amount $_______________________

(PLEASE DO NOT LIST FINANCIAL ACCOUNT NUMBERS)

Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other

[ ] Yes

[ ] No

valuable property, excluding ordinary household furnishings and clothing?

If "Yes" - describe the property and state its value.

[ ] Yes

[ ] No

Do you have any other assets?

If "Yes" - list each asset and state its value.

Do you have any outstanding debts?

[ ] Yes

[ ] No

If "Yes" - list them. (If incarcerated, be sure to include any debts owed to the institution where you are

incarcerated as a result of disciplinary or other action.)

List your regular monthly household or other expenses:

List the persons who are dependent on you for support, state your relationship to each person, and

indicate how much you contribute to their support. If you are listing minor children as dependents,

please list only the initials of the minor child (not full name)

I declare under penalty of perjury that the above information is true and correct. I understand that a false or

dishonest answer to a question in this affidavit may be punishable by fine or imprisonment or both.

____________________________

________________________________________________________________

DATE

SIGNATURE OF APPLICANT

USDCNH-13 (11-04) (Previous Editions Obsolete)

Motion Affidavit To Proceed In Forma Pauperis Without Prepayment Of Fees Page 2