Georgia > Statewide > Superior Court > Inmate-Habeas Corpus
Request To Proceed In Forma Pauperis (Habeas Corpus) HC-2 - Georgia
| Request To Proceed In Forma Pauperis (Habeas Corpus) Form. This is a Georgia form and can be used in Inmate-Habeas Corpus Superior Court Statewide . |
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IN THE SUPERIOR COURT OF STATE OF GEORGIA , Petitioner , Civil Action No. Inmate Number vs. , Habeas Corpus Warden (Name of Institution) Respondent REQUEST TO PROCEED IN FORMA PAUPERIS I, , depose and say that I am the plaintiff in the above entitled case; that in support of my request to proceed without being required to prepay fees, costs or give security therefor, I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am entited to redress. I further swear that the responses which I have made to questions and instructions below are true. 1. Are you presently employed? G Yes G 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 : If the answer is No, state the date of last employment and the amount of the salary and wages per month which you received : 2. Have you received within the past twelve months any money from any of the following sources? Business, profession or form of self-employment? G Yes G No Pensions, annuities or life insurance payments? G Yes G No Rent payments, interest or dividends? G Yes G No Gifts or inheritances? G Yes G No Any other sources? G Yes G No If the answer to any of the above is Yes, describe each source of money and state the amount received from each source during the past twelve months : 3. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in Administrative Office of the Courts (Revised 02-15-00) Form HC-2 <<<<<<<<<********>>>>>>>>>>>>> 2 prison accounts): G Yes G No If the answer is Yes, state the total value of the items owned : 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? G Yes G No If the answer is Yes, describe the property and state its approximate value : 5. List the persons who are dependent upon you for financial support, state your relationship to those persons, and indicate how you contribute toward their support : I understand that a false statement or answer to any question in this affidavit will subject me to penalties for perjury and that state law provides as follows: a. A person to whom a lawful oath or affirmation has been administered commits the offense of perjury when, in a judicial proceeding, he knowingly and willfully makes a false statement material to the issue on point in question. b. A person convicted of the offense of perjury shall be punished by a fine of not more than $1,000 or by imprisonment for not less than one nor more than ten years, or both. O.C.G.A.16-10-70. Signature of Petitioner Date VERIFICATION I am the plaintiff in this action and know the content of the above Request to Proceed in Forma Pauperis. I verify that the answers I have given are true of my own knowledge, except as to those matters that are stated in it on my information and belief, and as to those matters I believe them to be true. I have read the perjury statute set out above and am aware of the penalties for giving any false information on this form. Signature of Affiant Petitioner Date Sworn to and subscribed before me this _______ day of _____________________, 20_______. ______________________________________________________ Notary Public or Other Person Authorized to Administer Oaths Administrative Office of the Courts (Revised 02-15-00)- 2 - Form HC-2<<<<<<<<<********>>>>>>>>>>>>> 3 THIS FORM IS TO BE COMPLETED ONLY BY AN AUTHORIZED INDIVIDUAL AT THE INSTITUTION WHERE THE INMATE PLAINTIFF IS PRESENTLY INCARCERATED , OR HIS /HER DESIGNEE . CERTIFICATION I hereby certify that the Plaintiff herein, has an average monthly balance for the last twelve (12) months of $ on account atthe institution where confined. (If notconfined for a full twelve (12) months, specify the number of months confined. Then compute the average monthly balance on that number of months.) I further certify that Plaintiff likewise has the following securities according to the records of said institution : Authorized Officer of Institution Date NOTE: Please attach a copy of the prisoners inmate account of the last 12 months or the period of incarceration, whichever is less. Administrative Office of the Courts (Revised 02-15-00)- 3 - Form HC-2
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