Free Motion to Proceed In Forma Pauperis - Non Prisoner - Missouri

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI , Plaintiff(s), v. , Defendant(s). ) ) ) ) ) ) ) ) )

No.

MOTION TO PROCEED IN FORMA PAUPERIS AND FINANCIAL AFFIDAVIT

I,

, hereby apply for leave to proceed in

this action without prepayment of fees or costs and without giving security therefor. In support of this application, I declare that the following facts are true: (1) I am the plaintiff in this case and I believe I am entitled to relief.

(2) Because of my poverty I am unable to prepay the costs of this proceeding or to give security therefor. (3) The nature of my action, defense, or appeal is briefly stated as follows:

I declare under penalty of perjury that the foregoing is true and correct. Executed on , 20 .

Signature of plaintiff

CJA 23 Rev. 5/98 IN THE CASE OF

FINANCIAL AFFIDAVIT
IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE
IN UNITED STATES

G MAGISTRATE

G DISTRICT
FOR

G APPEALS COURT or

G OTHER PANEL (Specify below)
LOCATION NUMBER

V.S.
AT


1 G Defendant--Adult 2 G Defendant - Juvenile 3 G Appellant 4 G Probation Violator DOCKET NUMBERS Magistrate

PERSON REPRESENTED (Show your full name)


CHARGE/OFFENSE (describe if applicable & check box )

G Felony G Misdemeanor

5 G Parole Violator 6 G Habeas Petitioner 7 G 2255 Petitioner 8 G Material Witness 9 G Other (Specify)



District Court Court of Appeals

ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
Are you now employed? G Yes Name and address of employer:
EMPLOYMENT

G No

G Am Self-Employed
IF NO, give month and year of last employment How much did you earn per month? $

IF YES, how much do you earn per month? $ If married is your Spouse employed? IF YES, how much does your Spouse earn per month? $

G Yes

G No
If a minor under age 21, what is your Parents or Guardian's approximate monthly 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 the form of rent payments, interest, dividends, retirement or annuity payments, or other sources? G Yes G No ASSETS
OTHER INCOME
RECEIVED SOURCES

IF YES, GIVE THE AMOUNT RECEIVED & IDENTIFY THE SOURCES

$

CASH

Have you any cash on hand or money in savings or checking accounts?

G

Yes

G No

IF YES, state total amount $

Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? G Yes G No PROPERTY
VALUE DESCRIPTION

IF YES, GIVE THE VALUE AND $ DESCRIBE IT

OBLIGATIONS & DEBTS



DEPENDENTS



MARITAL STATUS SINGLE MARRIED WIDOWED SEPARATED OR DIVORCED APARTMENT OR HOME:

Total No. of Dependents


Creditors

List persons you actually support and your relationship to them

DEBTS & MONTHLY BILLS
(LIST ALL CREDITORS, INCLUDING BANKS, LOAN COMPANIES, CHARGE ACCOUNTS, ETC.)



Total Debt
$ $ $ $

Monthly Paymt. $
$ $ $

I certify under penalty of perjury that the foregoing is true and correct. Executed on (date) SIGNATURE OF DEFENDANT
(OR PERSON REPRESENTED)