IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
IN FORMA PAUPERIS AFFIDAVIT
Declaring that the information I have given below is true and correct, I apply to this court
for:
☐ appointment of an attorney.
☐ authority to commence an action without prepayment of fees, costs or security.
1. PERSONAL AND FINANCIAL DATA
A. Your full name and present mailing address:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Telephone (if any): _________________________________________________
B. Are you presently employed? Yes __________ No __________
If the answer is “yes,” give the name and address of your employer and the amount of
your usual weekly salary or wages.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Weekly earnings: $ _____________________________________________________
If you are not presently employed, give name and address of your last employer, when
you last worked, and the amount of weekly salary or wages you were receiving.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Date last worked: ___________________________________________________________
Weekly earnings: $ __________________________________________________________
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Approximately how much money have you received in the past twelve months:
as wages, salary, commissions, or earned income of any kind? $ ________________
as interest, dividends, rents, or investment income of any kind? $ ________________
as gifts or inheritance? $ ________________
from social security, unemployment compensation, or any form
of state or federal welfare payments or benefits? $ ________________
from pensions, annuities, workmen’s compensation, disability
or other insurance policies? $ ________________
from all other sources? $ ________________
C. (1) How much cash do you own or have? $ ________________
(2) How much money do you own or have in any
checking or savings account? $ ________________
D. Do you own any real estate, stocks, bonds, notes, automobiles, boats, or other valuable
property (excluding ordinary household items and clothing)? Yes ________ No ________
If the answer is “yes,” describe the property and state its approximate value:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
E. How much money do you owe others? $ ________________
As to each debt of over $100.00, state the name of the creditor, the approximate total amount
owed to that creditor, and the monthly payment amount you currently owe and/or are paying to
that creditor.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
F. List the persons who are dependent upon you for support, stating your relationship to
them and how much you contribute each year toward their support.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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G. Are there any other persons regularly residing in your household who are over the age of
18 and who are presently employed? Yes ________ No ________
If the answer is “yes,” give the following information for each such person:
Name: _________________________________________________________________
Relationship: ____________________________________________________________
Employer: ______________________________________________________________
Weekly earnings: $ _______________________________________________________
Name: _________________________________________________________________
Relationship: ____________________________________________________________
Employer: ______________________________________________________________
Weekly earnings: $ _______________________________________________________
H. Any other information which you believe supports your claim that you cannot financially
afford to employ an attorney or to make payment of court fees, costs, or security.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Attach additional sheets as needed)
II. EFFORTS TO OBTAIN ATTORNEY
(To be completed if requesting
Appointment of an attorney)
A. Have you talked with an attorney about handling your claim? Yes ______ No ______
If “yes,” give the following information about each attorney with whom you talked:
Attorney: _______________________________________________________________
When: _________________________________________________________________
Where: _________________________________________________________________
How (by telephone, in person, etc.) ___________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Attorney: _______________________________________________________________
When: _________________________________________________________________
Where: _________________________________________________________________
How (by telephone, in person, etc.) ___________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
B. Explain any other efforts you have made to contact an attorney to handle your claim.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
C. Any other information which supports your application for the court to appoint an
attorney for you:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
D. Name and address of each attorney who has represented you in the last ten (10) years for
any purpose:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(Attach additional sheets as needed)
III. ATTESTATION AND SIGNATURE
Under penalty of perjury, I declare that the information given on the preceding ____ pages is true
and correct.
Date: ___________________________ ___________________________________
SIGNATURE
WITNESS:
_________________________________
_________________________________
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