Fill and Sign the Forma Pauperis Form 497329928

IN THE ________________ (Name of Court) COURT OF ___________________ (County), __________________ (State) _________________________ PLAINTIFF (Name of Plaintiff) V. CAUSE NO. ________,________ _________________________ DEFENDANT (Name of Defendant) State of County of Affidavit of Indigency Personally appeared before me, the undersigned authority in and for said county and state, ____________________ (Name of Affiant) , who, i n order to be allowed to proceed in forma pauperis in the above-entitled action in ________________________________________ (Name of Court) , having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. I am unable to make prepayment of fees and costs or give security for fees and costs, and it is my belief that I am entitled to redress in the above-entitled action. 2. I have not, for the purpose of avoiding payment of costs, divested myself of any property, monies, or any items of value. 3. (Set forth brief statement as to nature of above-entitled action) . ________________ ______________________________________________________________________ ______________________________________________________________________. 4. My residence address is __________________________________________________ _______________________________ (street address, city, county, state, zip code) . 5. I am _____________________________________ (single or married or separated or divorced; if married, state full name of spouse) . 6. I have [no dependents, or, the following dependents: (state names and relationships, and monthly amounts of support contributed for each)] __________ ______________________________________________________________________ ______________________________________________________________________ . 7. I am [unemployed, and have been unemployed since (date of last employment] . ______________________________________________________________________. or, 7. I am employed, and the name and address of my Employer are as follows: ______________________________________________________________________ ______________________ (Name and address of Employer) . I have been employed by said Employer for (e.g., number of months or years) ____________________ , with a (e.g., weekly) _________________ salary of $____________ . My position with said Employer is (describe) ___________________________________________________ _____________________________, and my duties and responsibilities are (describe) ______________________________________________________________________ ______________________________________________________________________. 8. (If married, set forth employment status and information pertaining to spouse) ______________________________________________________________________ ______________________________________________________________________ . 9. (State ownership, if any, in real property, describing the property, its location, its estimated value, and the outstanding debt pertaining to it) . ___________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 10. (Describe personal property, such as automobiles, including its present value and the outstanding debt pertaining to it) _____________________________________ ______________________________________________________________________ ______________________________________________________________________. 11. The total amount of cash that I have on hand in accounts in banks, savings accounts, and other financial institutions is $____________. The names and addresses of these financial institutions are as follows: (list) _____________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________. 12. The total amount of money that I (and my spouse, if applicable) have invested in retirement accounts is $____________. The names and addresses of the institutions in which these accounts are maintained are as follows: (list) _______________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ . 13. In the last 12 months, I ________________ (have/have not) received monies from the sources listed below. (If monies were received from any of sources, set forth amounts and source) __________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ . 14. I am indebted to the following creditors, for the amounts indicated: (list names of creditors and amounts owed) ____________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________. Witness my signature this _____________________ (date) . _________________________________________ (Name and Signature of Affiant) SWORN to and subscribed before me, this the _____ day of ______________, 20____. _____________________________ NOTARY PUBLIC My Commission Expires: ____________________