Free Request to Proceed In Forma Pauperis - Georgia

UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF GEORGIA _______________________ Petitioner : : : : : : : : : :

AFFIDAVIT IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS

v. ________________________ Respondent(s)

I, _____________________________, being first duly sworn, depose and say that I am the petitioner in the above-entitled case; that in support of my motion to proceed without being required to prepay fees, costs or give security therefore, I state that because of my poverty that I am unable to pay the costs of said proceeding or to give security therefore; that I believe I am entitled to redress. I further swear that the responses which I have made to the questions below are true and complete. 1. State your residence. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 2. State the name and age of each member of your household. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

3.

Are you or any adult member of hour household (persons 18 years of age or older) employed? If so, state the name of each employed person, the name and address of the applicable employer, and the amount of such person's salary or wages per month.

_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 4. If you or any other adult member of your household is not presently employed, but has been previously employed, identify each such person and state the date of last employment and the amount of salary or wages received per month. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 5. Do you or any other member of your household own a home or other real estate? If so, describe each such property, state its approximate value and identify the owner. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 6. Do you or any other member of your household own an automobile or other vehicle? If so, identify the owner of each vehicle, and the make, model, year and approximate value of such vehicle. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 7. Do you or any other member of your household own any stock, bonds, notes, or other valuable (excluding ordinary household furnishing and clothing)? If so, describe each such item of property, its approximate value, and identify the owner. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

8.

Do you or any other member of your household have a checking and/or savings account, or other cash on hand? If so, state the total amount and owner of same. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

9.

Do you contribute to the support of any person who is not a member of your immediate household? If so, identify such person, his or her relationship to you, and the amount of support contributed per month. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

10.

Aside from income from employment, do you or any other household member have any other income? If so, identify each such person, the source of the income, and the monthly amount. (Include governmental sources, such as Social Security or other retirement benefits, disability benefits, veterans' benefits, unemployment benefits, AFDC payments workers' compensation benefits.) _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

11.

During the past 12 months, have you or any other household member received money from any sources not otherwise disclosed by your responses to the foregoing questions? For example, income from self-employment, rent payments, interest dividends, life insurance payments, gifts or inheritances.) If so, state the name of the household member who has such other income, the identity of such income, and the amount. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

12.

List the debts and monthly bills of your household income, including debts owing to banks, loan companies, charge accounts, etc. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Credit Total Debt Monthly Payment

_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

13.

If you feel that additional information would be helpful to the Court in ruling on your request to proceed in forma pauperis, state that information here. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT. Executed on this ___________ day of ___________________, 20__________.

__________________________ Signature of Movant