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UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK

-vs-

Plaintiff REQUEST TO PROCEED IN FORMA PAUPERIS Defendant(s)

, am the plaintiff in the above entitled case. I I, hereby request to proceed without being required to prepay fees or costs or give security therefore. I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therefore, and I believe I am entitled to redress. 1. If you are presently employed: a) give the name and address of your employer b) state the amount of your earnings per month

2.

If you are NOT PRESENTLY EMPLOYED: a) state the date of start and termination of your last employment b) state your earnings per month. YOU MUST ANSWER THIS QUESTION EVEN IF YOU ARE INCARCERATED.

3.

Have you received, within the past twelve months, any money from any source? If so, name the source and the amount of money you received. a) Are you receiving any public benefits? b) Do you receive any income from any other source? No No Yes, $ Yes, $

In Forma Pauperis Form-General - U.S. District Court-EDNY Rev. 6/2002

4.

Do you have any money, including any money in a checking or savings account? If so, how much?

5.

Do you own any apartment, house or building, stocks, bonds, notes, automobiles or other property? If the answer is yes, describe the property and state its approximate value. No Yes,

6.

List the person(s) that you pay money to support and the amount you pay each month.

7.

Do you pay for rent or for a mortgage? If so, how much each month?

S.

State any special financial circumstances which the Court should consider.

I understand that the Court shall dismiss this case if I give a false answer to any question in this declaration. In addition, if I give a false answer I will be subject to the penalties for perjury. I declare under the penalty of perjury that the foregoing is true and correct.

Dated: (signature)
rev. 7/2002