Fill and Sign the Financial Affidavit PDF Form

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO -vs- No. _____________________________ FINANCIAL AFFIDAVIT, APPLICATION TO PROCEED IN FORMA PAUPERIS AND ORDER (28 U.S. C. § 1915) I, ________________________________, make under oath the following statement regarding my financial, residential, marital and employment status, and since I am unable to prepay fees and costs in the above-entitled case, make application to proceed as a pauper in accordance with 28 U.S.C. § 1915: A. BACKGROUND AND RESIDENCE 1. Full Name: _______________________________________________________ 2. Age: __________ Sex: __________ 3. Present address: ___________________________________________________ 4. How long at this address? __________ Telephone No. ________________ 5. Married? _______ Single? _______ Divorced? _______ Separated? _______ 6. Number of dependents: _____________________________________________ 7. Ages of children living with you: ______________________________________ 8. List relationship of other dependents living with you: _________________________________________________________________ _________________________________________________________________ 9. List any dependents in items 7 and 8 depending on you for support: _________________________________________________________________ _________________________________________________________________ B. EMPLOYMENT AND INCOME 1. Are you now employed? ___________ Are you self-employed? ____________ 2. Name and address of employer: _______________________________________ _________________________________________________________________ 3. Position: _______________________ Salary per month: $_________________ 4. If self-employed, nature of business: ___________________________________ 5. Income previous month from self-employment: $_________________________ 6. If unemployed, how long since last job or self-employment: ________________ 7. Any other income such as disability pay, worker’s compensation, social security, pension, interests, note and loan repayments, dividends, trust funds, unemployment compensation? ________________________________________ 8. If so, indicate source and amount per month: $___________________________ 9. Total monthly net income: $__________________________________________ C. ASSETS 1. Do you own any real estate? Yes __________ No __________ a. Description: ________________________________________________ b. Location: __________________________________________________ c. Estimated Present Value: ______________________________________ d. Estimated outstanding mortgages or contracts on property: ___________ ___________________________________________________________ e. Payments per month: _________________________________________ 2. Do you own any automobiles? Yes __________ No ___________ a. Make: _______________ Model: _______________ Year: _________ b. Present value: _____________ Total amount owed: _______________ c. Monthly Payments: ___________________________________________ 3. Do you have any stocks or bonds? Yes __________ No ___________ a. Describe: __________________________________________________ b. Present Value: _______________________________________________ 4. Do you have any cash in the bank? Yes __________ No ___________ a. If so, indicate amount: ________________________________________ 5. Do you have any cash in savings and loan associations? Yes _____ No ______ 6. Do you have any other assets not listed above, excluding household furnishings and clothing? Yes __________ No ___________ a. If so, describe and give value: __________________________________ ___________________________________________________________ D. DEBTS AND OTHER OBLIGATIONS 1. Rent _______________ per month 2. Utilities _______________ per month 3. Creditors: List: Total Due Monthly Payment _______________ ______________ _______________ _______________ ______________ _______________ _______________ ______________ _______________ _______________ ______________ _______________ _______________ ______________ _______________ _______________ ______________ _______________ _______________ ______________ _______________ _______________ ______________ _______________ 4. Total Monthly Payments: $ __________________________________________ Signature of Applicant/Affiant SUBSCRIBED AND SWORN to before me this ______ day of ________________, __________. __________________________________________ Notary Public My Commission Expires: ______________________ O R D E R G The Court has considered the foregoing Affidavit and Application and the same is DENIED . G The Court has considered the foregoing Affidavit and Application and the same is GRANTED . It is ordered that the commencement and prosecution of the above- entitled suit, action, or proceeding is authorized without the prepayment of the filing fee, costs, or security therefor. However, any further proceedings involving costs must be specifically authorized in advance by the Court. DONE at ____________ this ____ day of ______________, ____. __________________________________________ UNITED STATES MAGISTRATE JUDGE IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO Plaintiff(s), -vs- No. _______________________ Defendant(s). ORDER FOR SERVICE OF PROCESS This matter is before the Court sua sponte pursuant to 28 U.S.C. § 1915(d), it appearing to the Court that plaintiff is proceeding under 28 U.S.C. § 1915, and that personal service of the summons and complaint is required in this matter, IT IS THEREFORE ORDERED that the U. S. Marshal is directed to serve the summons and complaint personally on defendant(s) as directed by the Clerk. __________________________________________ UNITED STATES MAGISTRATE JUDGE