Free Motion to Proceed In Forma Pauperis - Habeas Corpus - Missouri

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UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI
Petitioner
VS.

Respondent

) ) ) ) ) ) ) ) ) ) ) )

Case No.

MOTION TO PROCEED IN FORMA PAUPERIS AND AFFIDAVIT IN SUPPORT HABEAS CASES I declare (1) that I am the petitioner in this case; (2) that because of my poverty I am unable to pay the filing fee and (3) that I believe I am entitled to relief. The nature of my action and the issues are briefly stated as follows.

In further support of this application, questions 1. Place of confinement of petitioner:

I answer the following

2. Crime(s) for which you have been convicted, date and sentence on each:

3. Are you presently employed? a.

Yes

No

If the answer is ''yes state the amount of your salary or wages per month and give the name and address of your employer.

b.

If the answer is ''no state the date of last employment and the amount of the salary and wages per month which you received.

4. Have you received within the past twelve (12) months, money from any of the following sources? Yes No Business profession or form of self-employment? Rent payments interest or dividends? Pensions annuities or life insurance payments? Gifts or inheritances? Any other sources?
,

If the answer to any of the above is ''yes 11 describe the source and amount of money received from each during the past twelve (12) months.

5. Do you own any cash or do you have money in a checking or savings account? Include any funds in your prison account. No Yes If the answer is ''yes state the total amount of cash owned, and the balance in all checking savings or prison accounts.

6. Do you own real estate stocks bonds notes automobiles, other valuable property (excluding ordinary household furnishings and clothing)'~' No Yes If the answer is ''yes approximate value.

or

describe the property and state its

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7. List the persons who are dependent upon you for support state your relationship to those persons and indicate how much you contribute toward their support

I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT PROVIDING FALSE INFORMATION MAY SUBJECT ME TO CRIMINAL PROSECUTION IMPOSITION OF A FINE OR OTHER SANCTION THAT MAY ADVERSELY AFFECT MY ABILITY TO PURSUE THIS CASE OR OTHER CASES. I HAVE REVIEWED MY ANSWERS TO INSURE THEIR ACCURACY Executed (signed) this day of . F 20

(Signature of petitioner)

Certificate I certify that the applicant named herein has the sum of on account to his credit at the is institution where he confined. I further certify that the applicant likewise has the following securities to his credit according to the records of said institution: $

Authorized Officer of Institution

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