Free Application to Proceed in Forma Pauperis (non-prisoner cases)  - Tennessee

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF TENNESSEE ) ) ) ) )

v.

NO. __________ (To be assigned by the Clerk's Office. Do not write in this blank.)

APPLICATION TO PROCEED IN FORMA PAUPERIS WITH SUPPORTING DOCUMENTATION

I, [] [] [] plaintiff/petitioner defendant/respondent Other:

, declare that I am the:

in the above-reverenced proceeding. In support of my request to proceed without being required to prepay fees or give security therefor, I state that because of my poverty, I am unable to pay the fees for this action or give security therefor. I believe that I am entitled to the relief sought in my complaint/petition/answer/response. The nature of my action, defense, or other proceeding or the issues I intend to present are briefly stated as follows:

In further support of this application, I answer the following questions:

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PERSONAL INFORMATION, EMPLOYMENT AND INCOME DATA NAME (First Middle Last) YEAR OF BIRTH

SOCIAL SECURITY NUMBER (last 4 digits only)

PHONE NOS.

HOME ADDRESS:

OWN OR RENT?

HOW LONG AT CURRENT ADDRESS?

MARITAL STATUS:

NAME AND ADDRESS OF CURRENT EMPLOYER:

TELEPHONE NUMBER OF EMPLOYER:

HOW LONG AT CURRENT EMPLOYMENT?

OCCUPATION (Describe what you do):

IF EMPLOYED, STATE BOTH THE GROSS AND NET AMOUNTS OF YOUR SALARY AND WAGES PER MONTH. GROSS: NET:

IF NOT CURRENTLY EMPLOYED, GIVE MONTH AND YEAR OF LAST EMPLOYMENT: HOW MUCH DID YOU EARN PER MONTH AT YOUR LAST EMPLOYMENT:

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HAVE YOU RECEIVED ANY MONEY FROM ANY OF THE FOLLOWING SOURCES WITHIN THE PAST TWELVE MONTHS? Business, professional or other form of self-employment? If YES, state the source and amount: [ ] Yes [ ] No

Rent payments, interest, or dividends? If YES, state the source and amount:

[ ] Yes

[ ] No

Pensions, annuities, or life insurance payments? If YES, state the source and amount:

[ ] Yes

[ ] No

Gifts or inheritance? If YES, state the source and amount:

[ ] Yes

[ ] No

Any other source? If YES, state the source and amount:

[ ] Yes

[ ] No

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ASSETS: LIST ANY OF THE FOLLOWING ASSETS THAT YOU OWN AND THE TOTAL VALUE CASH CHECKING ACCOUNTS TOTAL BALANCE (List Banks Below) (Do NOT include account numbers) $ $

SAVINGS ACCOUNTS­TOTAL BALANCE (List Banks Below) (Do NOT include account numbers)

$

STOCKS AND BONDS REAL ESTATE­CURRENT FAIR MARKET VALUE (List Locations Below) $

$

$

$ TOTAL REAL ESTATE $

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VALUE OF PERSONAL PROPERTY, EXCLUDING VEHICLES (Itemize) $ $ $ TOTAL PERSONAL PROPERTY MOTOR VEHICLES Year/Make License No. Current Value $ $ $ TOTAL VALUE OF MOTOR VEHICLES DEBTS OWED TO YOU (Give Name of Debtor) $ $ $ TOTAL DEBTS OWED TO YOU OTHER ASSETS (ITEMIZE) $ $ $ TOTAL OTHER ASSETS $ $ $ $

TOTAL OFF ALL ASSETS: $

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LIABILITIES (DO NOT INCLUDE ACCOUNT NUMBERS) NOTES (LOANS) PAYABLE TO BANKS (List bank name and amount of loan only) $ $ $ TOTAL LOANS PAYABLE TO BANKS NOTES (LOANS PAYABLE TO OTHERS) MORTGAGES PAYABLE ON REAL ESTATE CREDIT CARDS AND ACCOUNTS PAYABLE TO CREDITORS MEDICAL BILLS TAXES AND ASSESSMENTS PAYABLE OTHER LIABILITIES (Itemize) $ $ $ $ $ $

$ $ $ TOTAL LIABILITIES $

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LIVING EXPENSES Monthly Payment [ ] RENT or [ ]MORTGAGE PAYMENT (check one)$ ELECTRICITY $ WATER $ GAS $ TELEPHONE $ FOOD $ ALIMONY $ CHILD SUPPORT $ CHILD CARE $ SCHOOL EXPENSES $ AUTOMOBILE NOTE $ AUTOMOBILE INSURANCE $ AUTOMOBILE REPAIRS $ GASOLINE $ FURNITURE NOTE $ CLOTHING $ CABLE TELEVISION $ LIFE INSURANCE $ HOSPITALIZATION INSURANCE $ DOCTORS $ DRUGS $ CREDIT CARDS $ OTHER CHARGE ACCOUNTS OR CREDITORS $ TAXES $ ANY OTHER EXPENSES (LIST) $ $ $ $ Balance Owing $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$ $ $ $

TOTAL EXPENSES

$

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SPOUSES' PERSONAL INFORMATION; EMPLOYMENT AND INCOME DATA NAME (First Middle Last) YEAR OF BIRTH

SOCIAL SECURITY NUMBER (last 4 digits only)

PHONE NOS.

HOME ADDRESS (if different from yours):

OWN OR RENT?

HOW LONG AT CURRENT ADDRESS?

NAME AND ADDRESS OF CURRENT EMPLOYER:

TELEPHONE NUMBER OF EMPLOYER:

HOW LONG AT CURRENT EMPLOYMENT?

OCCUPATION (Describe what your spouse does):

SPOUSE'S CURRENT MONTHLY INCOME: Salary or Wages Commissions All other sources (Pensions; Soc.Sec.; Rent; Interest; Dividends; Alimony, etc.) $ $

$

TOTAL:

$

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NAME OF DEPENDENTS AND INCOME (If any) (For Minor Children, only provide first initials)

Names:

Age:

Relationship:

Living With Whom?

TOTAL MONTHLY INCOME OF DEPENDENTS INCLUDING CHILD SUPPORT PAYMENTS (exclude spouse) $

TOTAL MONTHLY INCOME OF APPLICANT, SPOUSE, AND DEPENDENTS

$

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AFFIDAVIT

I hereby certify that the above statement is true and that it is a complete statement of all my income and assets, real and personal, whether held in my name or by any other, under penalty of perjury.

DATE

SIGNATURE

Created: January 31, 2007 IPF Application.wpd

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