Free PDF - New Mexico

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO

Plaintiff(s), v. No.

Defendant(s),

MOTION TO PROCEED IN FORMA PAUPERIS WITH FINANCIAL AFFIDAVIT PURSUANT TO 28 U.S.C. § 1915 I, ______________________________, make under oath the following statement regarding my financial, residential, marital and employment status, and since I am unable to prepay fees and costs in the above-entitled cause, make application to proceed as a pauper in accordance with 28 U.S.C. § 1915: A. BACKGROUND AND RESIDENCE 1. 2. 3. 4. 5. 6. 7. 8. Full Name:________________________________________________ Age:____________ Sex___________ Present address:___________________________________________ How long at this address:_________ Phone No:________________ Married?_____ Single?_____ Divorced?_____ Separated?_____ Number of dependents:_____________ Ages of children living with you:________________________________ List of relationship of other dependents living with you: _________________________________________________________ 9. List any dependents in items 7 and 8 depending on you for support: _________________________________________________________

B.

EMPLOYMENT AND INCOME 1. 2. Are you now employed?______ Are you self-employed?______

Name and address of employer:________________________________ _________________________________________________________

3. 4. 5. 6. 7.

Position:______________________ Salary per month:$____________ If self-employed, nature of business:____________________________ Income previous month from self-employment:____________________ If unemployed, how long since last job or self-employment:__________ Any other income such as disability pay, workmen's compensation, social security, pension, interests, note and loan repayments, dividends, trust funds, unemployment compensation?______________ If so, indicate source and amount per month: $___________________ Total monthly net income: $__________________

8. 9. C. ASSETS 1.

Do you own any real estate? Yes_____ No_____ a. b. c. d. e. Description__________________________________________ Location____________________________________________ Estimated present value: $___________________ Estimated outstanding mortgages or contracts on property: $________________ Payments per month: $________________

2.

Do you own any automobiles? a. b. c. Make____________ Model______________ Year__________ Present value: $_________ Total amount owed $___________ Monthly payments: $_____________

3.

Do you have any stocks or bonds? a. b.

Yes_____ No_____

Describe:____________________________________________ Present value: $________________ Yes_____ No_____

4. 5. 6.

Do you have any cash in bank?

Do you have any cash in savings and loan associations? Yes_____ No_____ Do you have any other assets not listed above excluding household furnishings and clothing? Yes_____ No_____ a. If so describe and give value:____________________________ ___________________________________________________

D.

DEBTS AND OTHER OBLIGATIONS 1. 2. 3. Rent $______________ per month Utilities $_____________per month Creditors: List _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ 4. Total Monthly Payments: Total Due _____________ Monthly Payment ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________

_____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________

$_____________________

____________________________________ Signature of Applicant/Affiant SUBSCRIBED AND SWORN to before me this ____ day of ____________, 200__. ____________________________________ Notary Public My Commission Expires: _______________________