(a) All actions sought to be filed in forma pauperis, pursuant to 28 U.S.C. §
1915, shall be accompanied by an affidavit of inability to pay costs or give security. This
affidavit shall consist of a declaration in support of request to proceed in forma pauperis.
This declaration shall contain the following:
(1) A statement as to current employment including the amount of
wages or salary per month and the name and address of the current employer.
(2) A statement, if not currently employed, as to the date of last
employment and the amount of wages or salary per month which was received.
(3) A statement as to any money received within the past twelve months
from any of the following sources:
(A) Business, profession, or self-employment;
(B) Rent payments, interest, or dividends;
(C) Pensions, annuities, or life insurance payments;
(D) Gifts or inheritances; and
(E) Any other source.
The statement shall include a description of each source of money and the amount
of money received from each source during the past twelve months.
(4) A statement as to any cash in possession and as to any money in a
financial institution, including checking, savings, and any other accounts. The statement
shall include any money available to the declarant.
(5) A statement as to any real estate, stocks, bonds, notes, automobiles,
investments, or other valuable property (excluding ordinary household furnishings and
clothing). The statement shall describe the property and state its approximate value.
(6) A statement as to all persons who depend upon the declarant for
support. The statement shall include the relationship of the dependents and the amount
contributed toward their support.
(7) A statement that, because of poverty, there is an inability to pay the
costs of the proceeding or given security therefore, and the declarant's belief that the
declarant is entitled to relief.
(b) In actions by persons who are incarcerated, this declaration must contain a
certification, executed by an authorized officer of the institution, as to any amount
contained in any of declarant's accounts at the institution.
This declaration shall be executed under penalty of perjury.
