Non Prisoner Application To Proceed Without Prepayment Of Fees And Affidavit

United States District Court WESTERN DISTRICT OF KENTUCKY NON-PRISONER APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT ____________________, Plaintiff v. ____________________, Defendant(s) CASE NUMBER: I, ______________________________, swear or affirm under penalty of perjury that I am the (check appropriate box) " petitioner/plaintiff/movant " other _________________ in the above-named proceeding, that I am unable to pay the costs of these proceedings, and that I believe I am entitled to the relief sought in the complaint/petition/motion. I further swear or affirm under penalty of perjury under United States laws that my answers on this form and any attachments are true and correct. Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is "0", "none," or "not applicable (N/A)," write in that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name and the question number. NOTE: You should be prepared to provide the Court with copies of documents that support or verify all your answers to the questions in this application. Signed: ________________________________ Print your Name: ________________________ 1. State the address of your legal residence ___________________________________________________________________________________________ ___________________________________________________________________________________________ Your daytime phone number: 2. ___________________________ Date: ___________________________ For both you and your spouse, estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. Income Source Average monthly amount during the past 12 months YOU SPOUSE $ $ $ $ Amount expected next month YOU $ $ SPOUSE Employment Self-employment Income from real property (such as rental income) Interest & dividends $ $ $ $ $ $ $ $ $ $ Page 1 of 5 American LegalNet, Inc. www.USCourtForms.com Income Source Average monthly amount during the past 12 months YOU SPOUSE $ $ $ $ $ $ Amount expected next month YOU $ $ $ SPOUSE Gifts or Inheritance Alimony Child support Retirement (such as social security, pensions, annuities, insurance) Disability (such as social security, insurance payments) Unemployment payments Public assistance (such as welfare) Other (specifiy) ___________________ ___________________ Total Monthly Income $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 3. Are you currently employed? Is your spouse currently employed? " Yes " Yes " No " No 4. List your employment history, current or, if you are not currently employed, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer a. Address Dates of Employment Gross Monthly Pay $____________________ b. $____________________ c. $____________________ Page 2 of 5 American LegalNet, Inc. www.USCourtForms.com . List your spouse's employment history, current or, if your spouse is not currently employed, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer a. b. c. Address Dates of Employment Gross Monthly Pay $ __________________ $ __________________ $ __________________ 6. How much cash do you and your spouse have? $ ___________________ Below, state any money you or your spouse have in checking or savings accounts or in any other financial institution. Financial Institution Type of Account Amount You Have $ __________________ $ __________________ $ __________________ Amount Your Spouse Has $ __________________ $ __________________ $ __________________ a. b. c. 7. List the assets, and their values, that you own or your spouse owns. Do not list clothing and ordinary household furnishings. Asset a. Home b. Real Estate c. Motor Vehicle Make & Year: Model: Registration #: Make & Year: Model: Registration #: Description Value $ __________________ $ __________________ $ __________________ d. Motor Vehicle $ __________________ e. Other Assets (for example, stocks, bonds, securities or other financial instruments) f. Other Assets $ __________________ $ ____________________ Page 3 of 5 American LegalNet, Inc. www.USCourtForms.com 8. State every person, business, or organization owing you or your spouse money, and the amount owed. Who owes you or your spouse money? Amount owed to you $ __________________ $ __________________ $ __________________ $ __________________ Amount owed to your spouse $ __________________ $ __________________ $ __________________ $ __________________ a. b. c. d. 9. State the persons who rely on you or your spouse for support. Name Relationship Age Amount Contributed Monthly for His/Her Support $ ____________________ $ ____________________ $ ____________________ $ ____________________ Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any amount that was received weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate. Expense You $ _______________________ Your Spouse $ ______________________ a. b. c. d. 10. Rent or home mortgage payment (include lot rented for mobile home) Are real estate taxes included? " Yes " No Is property insurance included? " Yes " No Utilities (electricity, heating fuel, water, sewer, telephone) Home maintenance (repairs and upkeep) Food Clothing Laundry and dry cleaning Medical and dental expenses Transportation (not including motor vehicle payments) Recreation, entertainment, newspapers, magazines, etc. $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ Page 4 of 5 American LegalNet, Inc. www.USCourtForms.com Expense Insurance (not deducted from wages or included in mortgage payments. Homeowner's or renters: Life: Health: Motor Vehicle: Other: Taxes (not deducted from wages or included in mortgage payments)(specify):_______________ __________