Free F55 - New York

UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF NEW YORK
In re ,) ) ) ) ) or ) ) ) ) ) ,) ) ) ) ) ,)

[Set forth here all names including married, maiden, and trade names used by debtor within last 6 years.]

Debtor Social Security No(s). Employer's Tax Identification No(s). [if any]

Case No. Chapter

Plaintiff v.

Adv. Proc. No.

Defendant

APPLICATION TO PROCEED IN FORMA PAUPERIS, SUPPORTING DOCUMENTATION

I, petitioner/plaintiff respondent/defendant

, declare that I am the (check appropriate box) movants (filing 28 U.S.C. §2255 motion) Other

in the above-entitled proceeding; that, in support of my request to proceed without being required to prepay fees, cost or give security, I state that because of my poverty, I am unable to pay the costs of said proceeding or give security; that I believe that I am entitled to relief. The nature of my action, defense or other proceeding or the issues I intend to present on appeal are briefly stated as follows:

In further support of this application, I answer the following questions 1. Are you presently employed? Yes No

a. If the answer is "yes" state the amount of your salary or wages per month, and give the name and address of your employer (list both gross and net salary)

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.

F:55(04/10/2000)

2.

Have you received within the past twelve months any money form any of the following sources? a. Business, profession or other form of self employment? b. Rent payments, interest or dividends? c. Pension, annuities or life insurance ? d. Gifts or inheritances? e. Any other sources? Yes Yes Yes Yes Yes No No No No No

If the answer to any of the above is "yes" describe each source of money and state the amount received for each during the past twelve months.

3.

Do you own any case or do you have money in checking or savings accounts? Yes No (Include any funds in prison accounts)

If the answer is "yes", state the total value of the items owned.

4.

Do you own or have any interest in any real estate, stocks, bonds, notes, automobiles or other valuable property (excluding ordinary household furnishings and clothing)? Yes No

If the answer is "yes", describe the property and state its approximate value.

5.

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 foregoing is true and correct.

Executed on
Date Signature of Applicant

CERTIFICATE
(Prisoner Accounts Only)

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

I further certify that during the last six months the applicant's average balance was . $

Authorized Officer of Institution

F:55(04/10/2000)