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UNITED STATES BANKRUPTCY COURT FOR THE NORTHERN DISTRICT OF WEST VIRGINIA

IN RE:

Debtor(s).

§ § § § § §

BK NO.

IN FORMA PAUPERIS FINANCIAL AFFIDAVIT

NAME (Last, First, Middle Initial): _________________________________________________ ADDRESS: ___________________________________________________________________ MARITAL STATUS: Single ___ Married ___ Widowed ___ Divorced/Separated ___ DEPENDENTS: _____ LIST PERSONS YOU ACTUALLY SUPPORT AND YOUR RELATIONSHIP TO EACH: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ EMPLOYMENT: Are you now employed? Yes ___ No ___ If Yes, state name and address of employer: __________________________________________ ________________________________________________________________________ How long have you been employed by present employer? _______________________________ Income per month: $_____________________________________________________________

If No, give month and year of last employment: _______________________________________ How much did you earn per month? $_______________________________________________ If you are married, is your spouse employed? Yes ___ No. ___ If Yes, state amount earned by spouse per month: $_______________________________ OTHER INCOME: Have you received within 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 from any other source? Yes ___ No. ___ If Yes, give the amount received and identify the sources: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ CASH: Do you have any cash on hand, or any money in savings or checking accounts? Yes ___ No ___ If Yes, state the total amount: $____________________________________________________ PROPERTY: Do you own any real estate, automobiles, stocks, bonds, notes, or other valuable property (excluding ordinary household furnishings and clothing)? Yes ___ No ___ If Yes, please describe the property and give its estimated value: Description Value

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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DEBTS AND MONTHLY BILLS: List all creditors, including banks, loan companies, charge accounts, etc.: Creditor Total Debt Monthly Payment

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ OTHER INFORMATION PERTINENT TO FINANCIAL STATUS: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

I hereby certify the above information to be correct, and understand that a false or dishonest answer to a question in this affidavit may be punishable by fine, imprisonment, or both. ____________________________________________ SIGNATURE ________________________ DATE

Subscribed and sworn before me this _____ day of _______________, 20____. _______________________________________________________________ _______________________________________________________________

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