FINANCIAL AFFIDAVIT In Support of a Motion to Proceed In Forma Pauperis Case Name: Docket Number: EMPLOYMENT Are you now employed? ___ Yes ___ No ___ Self Employed Name & Address of Employer: ___________________________________________________ If YES, how much do you earn per month? $__________________ If NO, give month & year of last employment _________________ How much did you earn per month? _________________________ If married, is your spouse employed? ___ Yes ___ No If YES, how much does your spouse earn per month? $___________________ If a minor under age 21, what is your parents' or guardian's approximate monthly income? $___________________________ OTHER INCOME Have you received in the past 12 months any income from a business, profession, or other form of self-employment, or in the form of rent, payments, interest, dividends, retirement or annuity payments, or other sources? ___ Yes ___ No If YES, give the amount received and identify sources: Received ____________________ ____________________ ____________________ ____________________ CASH Have you any cash on hand or money in savings, a prisoner trust fund account or checking account? ___ Yes ___ No If YES, state total amount $___________ Sources: ________________________________________ ________________________________________ ________________________________________ ________________________________________ _____________________________ _____________________________
PROPERTY Do you own any real estate, stock, bonds, notes, automobiles or other valuable property (excluding ordinary household furnishings and clothing?) ___ Yes ___ No If YES, give value and describe it: Value ____________________ ____________________ ____________________ ____________________ DEPENDENTS Marital status: Total No. of Dependents: ________________ ___ Single ___ Married ___ Widowed ___ Separated or Divorced List persons you actually support & your relationship ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ DEBTS & MONTHLY BILLS List all creditors, including banks, loan companies, charge accounts, etc. Total Debt: $__________ $__________ $__________ $__________ Monthly Payment: $__________ $__________ $__________ $__________ Description ________________________________________ ________________________________________ ________________________________________ ________________________________________
Creditors: Apt. or Home: _____________________ _________________________________ _________________________________ _________________________________
I certify the above to be correct.
_______________________________ Signature of movant
WARNING: A false or dishonest answer to a question in this affidavit may be punishable by fine, imprisonment, or both.