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Financial Affidavit In Support Of A Motion To Proceed In Forma Pauperis - Official Federal Forms
| Financial Affidavit In Support Of A Motion To Proceed In Forma Pauperis Form. This is a national form and can be used in 2nd Circuit Court Of Appeals Circuit Court Of Appeals . |
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FINANCIAL AFFIDAVIT In Support of a Motion to Proceed In Forma Pauperis Case Name: Docket Number: EMPLOYMENT _____________________________ _____________________________ Are you now employed? Yes No Self Employed Name & Address of Employer: ___________________________________________________ If YES, how much do you earn per month? $__________________ If NO, give month & year of last employment _________________ How much did you earn per month? _________________________ If married, is your spouse employed? Yes No If YES, how much does your spouse earn per month? $___________________ If a minor under age 21, what is your parents' or guardian's approximate monthly income? $___________________________ OTHER INCOME Have you received in the past 12 months any income from a business, profession, or other form of self-employment, or in the form of rent, payments, interest, dividends, retirement or annuity payments, or other sources? Yes No If YES, give the amount received and identify sources: Received ____________________ ____________________ ____________________ ____________________ CASH Have you any cash on hand or money in savings, a prisoner trust fund account or checking account? Yes No If YES, state total amount $___________ Sources: ________________________________________ ________________________________________ ________________________________________ ________________________________________ rev.11/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com PROPERTY Do you own any real estate, stock, bonds, notes, automobiles or other valuable property (excluding ordinary household furnishings and clothing?) Yes No If YES, give value and describe it: Value ____________________ ____________________ ____________________ ____________________ DEPENDENTS Marital status: Total No. of Dependents: ________________ Description ________________________________________ ________________________________________ ________________________________________ ________________________________________ Single Married Widowed Separated or Divorced List persons you actually support & your relationship ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ DEBTS & MONTHLY BILLS List all creditors, including banks, loan companies, charge accounts, etc. Total Debt: $__________ $__________ $__________ $__________ Monthly Payment: $__________ $__________ $__________ $__________ __________ Date Creditors: Apt. or Home: _____________________ _________________________________ _________________________________ _________________________________ I certify the above to be correct. _______________________________ Signature of movant WARNING: A false or dishonest answer to a question in this affidavit may be punishable by fine, imprisonment, or both. Attach this completed Financial Affidavit to a completed T-1080 Motion Information Statement, available on the Court's website. rev.11/17/2011 American LegalNet, Inc. www.FormsWorkFlow.com
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