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In Forma Pauperis Application And Financial Affidavit - Illinois
| In Forma Pauperis Application And Financial Affidavit Form. This is a Illinois form and can be used in USDC Northern Federal . |
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7/18/02 UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS IN FORMA PAUPERIS APPLICATION AND FINANCIAL AFFIDAVIT ______________________________ Plaintiff v. CASE NU M BER____________________________ ______________________________ Defendant(s) JUDGE ____________________________________ Wherever G is included , please place an X into whichever box applies. Wherever the answer to any question requires more inform ation than the space that is provid ed, attach one or m ore p age s that refer to each such question number and provide the additional information. Please PRINT: I, _____________________________________, declare that I am the Gplaintiff Gpetitioner Gmovant (other________________) in the above-entitled case. This affidavit constitutes my application G to proceed without full prepayment of fees, or G in support of my motion for appointment of counsel, or G both. I also declare that I am unable to pay the costs of these proceedings, and that I am entitled to the relief sought in the complaint/petition/motion/appeal. In support of this petition/application/motion/appeal, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated? GYes GNo (If "No," go to Question 2) I.D. #______________________ Name of prison or jail:_________________________________ Do you receive any payment from the institution? GYes GNo Monthly amount:___________ Are you currently employed? GYes GNo Monthly salary or wages:___________________ Name and address of employer: _____________________________________________________ _______________________________________________________________________________ a. If the answer is "No": Date of last employment:____________________________________________________ Monthly salary or wages:______________________ Name and address of last employer:___________________________________________ ________________________________________________________________________ Are you married? GYes GNo Spouse's monthly salary or wages:_____________________ Name and address of employer:_______________________________________________ ________________________________________________________________________ 2. b. 3. Apart from your income stated above in response to Question 2, in the past twelve months have you or anyone else living at the same address received more than $200 from any of the following sources? Mark an X in either "Yes" or "No", and then check all boxes that apply in each category. a. Salary or wages GYes GNo Amount_______________________ Received by________________________________________ 2002 © American LegalNet, Inc. b. G Business, G profession or G other self-employment GYes GNo Amount_______________________ Received by_______________________________________ c. G Rent payments, G interest or G dividends GYes GNo Amount_______________________ Received by________________________________________ G Pensions, G social security, G annuities, G life insurance, G disability, G workers' compensation, G unemployment, G welfare, G alimony or maintenance or G child support GYes GNo Amount_______________________ Received by_______________________________________ d. e. G Gifts or G inheritances GYes GNo Amount______________________ Received by________________________________________ f. GAny other sources (state source:_____________________) GYes GNo Amount_______________________ Received by________________________________________ 4. Do you or anyone else living at the same address have more than $200 in cash or checking or savings accounts? GYes GNo Total amount:________________ In whose name held:_____________________ Relationship to you:_______________________ Do you or anyone else living at the same address own any stocks, bonds, securities or other financial instruments? GYes GNo Property:_______________________________ Current Value:____________________________ In whose name held:______________________ Relationship to you:_______________________ Do you or anyone else living at the same address own any real estate (houses, apartments, condominiums, cooperatives, two-flats, three-flats, etc.)? GYes GNo Address of property:______________________________________________________________ Type of property:________________________ Current value:_____________________________ In whose name held:____________________ Relationship to you:________________________ Amount of monthly mortgage or loan payments:________________________________________ Name of person making payments:___________________________________________________ Do you or anyone else living at the same address own any automobiles, boats, trailers, mobile homes or other items of personal property with a current market value of more than $1000? GYes GNo Property:_______________________________________________________________________ Current value:__________________________________________________________________ In whose name held:_______________________ Relationship to you:______________________ List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute monthly to their support. If none, check here GNo dependents _______________________________________________________________________________ ______________________________________________________________________________ 5. 6. 7. 8. -2- 2002 © American LegalNet, Inc. I declare under penalty of perjury that the above information is true and correct. I understand that pursuant to 28 U.S.C. § 1915(e)(2)(A), the court shall dismiss this case at any time if the court determines that my allegation of poverty is untrue. Date: _____________________ ______________________________________ Signature of Applicant ______________________________________ (Print Name) --------------------------------------------------------------------------------------------------------------------------------NOTICE TO PRISONERS: A prisoner must also attach a statement certified by the appropriate institutional officer or officers showing all receipts, expenditures and balances during the last six months in the prisoner's prison or jail trust fund accounts. Because the law requires information as to such accounts covering a full six months before you have filed your lawsuit, you must attach a sheet covering transactions in your own account--prepared by each institution where you have been in custody during that six-month period--and you must also have the Certificate below completed by
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