Georgia affidavit in support of request to proceed in forma pauperis
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UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF GEORGIA
_______________________
Petitioner:
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:
:
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:AFFIDAVIT IN SUPPORT OF REQUEST
TO PROCEED IN FORMA PAUPERIS
v.
________________________
Respondent(s)
I, _____________________________, being first duly sworn, depose and say that I am the
petitioner in the above-entitled case; that in support of my motion to proceed without being required
to prepay fees, costs or give security therefore, I state that because of my poverty that I am unable
to pay the costs of said proceeding or to give security therefore; that I believe I am entitled to
redress.
I further swear that the responses which I have made to the questions below are true and
complete.
1.State your residence.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
2.State the name and age of each member of your household.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
3.Are you or any adult member of hour household (persons 18 years of age or older)
employed? If so, state the name of each employed person, the name and address of the
applicable employer, and the amount of such person’s salary or wages per month.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
4.If you or any other adult member of your household is not presently employed, but has been
previously employed, identify each such person and state the date of last employment and
the amount of salary or wages received per month.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
5.Do you or any other member of your household own a home or other real estate? If so,
describe each such property, state its approximate value and identify the owner.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
6.Do you or any other member of your household own an automobile or other vehicle? If so,
identify the owner of each vehicle, and the make, model, year and approximate value of such
vehicle.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
7.Do you or any other member of your household own any stock, bonds, notes, or other
valuable (excluding ordinary household furnishing and clothing)? If so, describe each such
item of property, its approximate value, and identify the owner.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
8.Do you or any other member of your household have a checking and/or savings account, or
other cash on hand? If so, state the total amount and owner of same.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
9.Do you contribute to the support of any person who is not a member of your immediate
household? If so, identify such person, his or her relationship to you, and the amount of
support contributed per month.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
10.Aside from income from employment, do you or any other household member have any other
income? If so, identify each such person, the source of the income, and the monthly amount.
(Include governmental sources, such as Social Security or other retirement benefits, disability
benefits, veterans’ benefits, unemployment benefits, AFDC payments workers’
compensation benefits.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
11.During the past 12 months, have you or any other household member received money from
any sources not otherwise disclosed by your responses to the foregoing questions? For
example, income from self-employment, rent payments, interest dividends, life insurance
payments, gifts or inheritances.) If so, state the name of the household member who has
such other income, the identity of such income, and the amount.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
12.List the debts and monthly bills of your household income, including debts owing to banks,
loan companies, charge accounts, etc.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
CreditTotal DebtMonthly Payment_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
13.If you feel that additional information would be helpful to the Court in ruling on your request to
proceed in forma pauperis, state that information here.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING INFORMATION IS TRUE
AND CORRECT.
Executed on this ___________ day of ___________________, 20__________.
__________________________
Signature of Movant
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