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Application To Proceed In Forma Pauperis With Supporting Documentation (Judge Edgar And Judge Collier Only) - Tennessee
| Application To Proceed In Forma Pauperis With Supporting Documentation (Judge Edgar And Judge Collier Only) Form. This is a Tennessee form and can be used in Criminal USDC Eastern Federal . |
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IN THE UNITED STATES DISTRICT COURT EASTERN DISTRICT OF TENNESSEE ) ) v. ) NO. ) (To be assigned by the Clerks ) Office. Do not write in this ) blank.) APPLICATION TO PROCEED IN FORMA PAUPERIS WITH SUPPORTING DOCUMENTATION I, , declare that I am the: petitioner/plaintiff movant (filing 28 U.S.C. 2255 motion) respondent/defendant other in the above-referenced proceeding. In support of my request to proceed without being required to prepay fees or give security therefor,I state that because of my poverty, I am unable to pay the fees for this action or give security therefor. I believe that I am entitled to therelief sought in my complaint/petition. The nature of my action, defense, or other proceeding or the issues that I intend to present arebriefly stated as follows: In further support of this application, I answer the following questions: YOUR EMPLOYMENT AND INCOME DATA 1. NAME (First Middle Last) 2. BIRTH DATE (mo day yr) 3. SOCIAL SECURITY NO. 4. TELEPHONE NOS. - - 5. PRISONER NUMBER: 7. HOW LONG AT CURRENT HOME ADDRESS? 6. HOME ADDRESS? 8. OWN OR RENT? STREET: APT. NO.: CITY: STATE: ZIP CODE: <<<<<<<<<********>>>>>>>>>>>>> 29. CURRENT EMPLOYER (Including employment at the penal facility) STREET: CITY: STATE: ZIP CODE: 10. HOW LONG AT CURRENT EMPLOYMENT? 11. OCCUPATION (Describe what you do): 12. IF EMPLOYED, STATE BOTH THE GROSS AND NET AMOUNTS OF YOUR SALARY AND WAGES PER MONTH. GROSS: NET: 13. IF NOT CURRENTLY EMPLOYED, GIVE MONTH AND YEAR OF LAST EMPLOYMENT 14. HOW MUCH DID YOU EARN PER MONTH AT YOUR LAST EMPLOYMENT? 15. HAVE YOU RECEIVED ANY MONEY FROM ANY OF THE FOLLOWING SOURCES WITHIN THE PAST TWELVE MONTHS? a. Business, professional or other form of self-employment? Yes No If YES, state the source and amount: b. Rent payments, interest, or dividends? Yes No If YES, state the source and amount: c. Pensions, annuities, or life insurance payments? Yes No If YES, state the source and amount: d. Gifts or inheritance: Yes No If YES, state the source and amount e. Any other sources? Yes No If YES, state the source and amount 2 <<<<<<<<<********>>>>>>>>>>>>> 3 ASSETS: LIST ANY OF THE FOLLOWING ASSETS THAT YOU OWN AND THE TOTAL AMOUNT: 1. CASH $ 2. CHECKING ACCOUNTS--TOTAL BALANCE (List Banks Below) $ _________________________________ _________________________________ _________________________________ 3. SAVINGS ACCOUNTS--TOTAL BALANCE (List Banks Below) $ _________________________________ _________________________________ _________________________________ 4. STOCKS AND BONDS $ 5. REAL ESTATE--CURRENT FAIR MARKET VALUE (List Locations Below) $ $ $ TOTAL REAL ESTATE $ 6. VALUE OF PERSONAL PROPERTY, EXCLUDING VEHICLES (Itemize) $ $ $ $ TOTAL PERSONAL PROPERTY $ 3 <<<<<<<<<********>>>>>>>>>>>>> 47. MOTOR VEHICLES Year/Make License No. Current Value $ $ $ TOTAL VALUE OF MOTOR VEHICLES $8. DEBTS OWED TO YOU (List Name of Debtor) $ $ TOTAL DEBTS OWED TO YOU $9. OTHER ASSETS (ITEMIZE) $ $ $ TOTAL OTHER ASSETS $ TOTAL ASSETS $ 4 <<<<<<<<<********>>>>>>>>>>>>> 5 LIABILITIES: 1. NOTES (LOANS) PAYABLE TO BANKS (List Banks and Amount of Loans) $ $ $ TOTAL LOANS PAYABLE TO BANKS $ 2. NOTES (LOANS) PAYABLE TO OTHERS $ 3. MORTGAGES PAYABLE ON REAL ESTATE $ 4. CREDIT CARDS AND ACCOUNTS PAYABLE TO CREDITORS $ 5. MEDICAL BILLS $ 6. TAXES AND ASSESSMENTS PAYABLE $ 7. OTHER LIABILITIES (Itemize) $ $ $ TOTAL LIABILITIES $ 5 <<<<<<<<<********>>>>>>>>>>>>> 6 LIVING EXPENSES: *TO BE COMPLETED BY PRISONERS WHO HAVE BEEN RELEASED, BUT REMAIN ON PAROLE OR PROBATION OR ANY OTHER TYPE OF RELEASE PROGRAM. SEE 28 U.S.C. 1915(c). Monthly Payment Balance Owing RENT or MORTGAGE PAYMENT (Indicate Which) $ $ UTILITIES a. Electricity $ $ b. Water $ $ c. Gas $ $ d. Telephone $ $ e. Other $ $ FOOD $ $ ALIMONY $ $ CHILD SUPPORT $ $ CHILD CARE $ $ SCHOOL EXPENSES $ $ AUTOMOBILE NOTE $ $ AUTOMOBILE INSURANCE $ $ AUTOMOBILE REPAIRS $ $ GASOLINE $ $ FURNITURE NOTE $ $ CLOTHING $ $ CABLE TELEVISION $ $ LIFE INSURANCE $ $ HOSPITALIZATION INSURANCE $ $ DOCTORS $ $ DRUGS $ $ CREDIT CARDS (LIST/MONTHLY PAYMENTS) $ $ $ $ $ $ OTHER CHARGE ACCOUNTS OR CREDITORS $ $ TAXES $ $ ANY OTHER DEBTS (LIST) $ $ $ $ $ $ $ $ TOTAL EXPENSES $ 6 <<<<<<<<<********>>>>>>>>>>>>> 7 SPOUSES EMPLOYMENT AND INCOME DATA 1. NAME (First Middle Last) 2. BIRTH DATE (mo day yr) 3. SOCIAL SECURITY NO. 4. TELEPHONE NOS. - - 5. HOME ADDRESS (if different from yours) 6. HOW LONG AT CURRENT HOME ADDRESS? STREET: 7. OWN OR RENT? APT. NO.: CITY: STATE: ZIP CODE: 8. CURRENT EMPLOYER: 9. HOW LONG AT CURRENT EMPLOYMENT? STREET: CITY: STATE: ZIP CODE: 10. OCCUPATION (Describe what spouse does): 11. SPOUSES CURRENT MONTHLY INCOME: Salary of Wages $ Commissions $ All Other Sources (Pensions; Soc. Sec.; Rent; Interest; Dividends; Alimony; etc...): $ TOTAL $ 7 <<<<<<<<<********>>>>>>>>>>>>> 8 NAME OF DEPENDENTS AND INCOME (if any) Names: Age: Relationship: Living With Whom? TOTAL MONTHLY INCOME OF DEPENDENTS INCLUDING CHILD SUPPORT PAYMENTS (exclude spouse) $ TOTAL MONTHLY INCOME OF APPLICANT, SPOUSE, AND DEPENDENTS $ 8 <<<<<<<<<********>>>>>>>>>>>>> 9I declare under penalty of perjury that the above information is true an d correct. (Date) (Signature of Applicant) CERTIFICATE TO BE COMPLETED BY AN AUTHORIZED CUSTODIAN OF INMATE ACCOUNTS I certify that the applicant herein has the sum of $ on account to his/her credit at the (institution where the applicant is currently incarcerated). I furthe rcertify that the average balance in the applicants trust fund accoun t during the last six months was$ . A copy of the applicants trust fund account (or an institutional equivalent) for the last six monthsis attached hereto. (Signature of Authorized Officer)Sworn and subscribed before me this day of , 20 . Notary Public My commission expires: 9
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