Application For Appointment Of Pro Bono Counsel (Non-Debtor-Contested Matter)

UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF COLUMBIA In re ______________________________ ) ) ) ) Debtor. ) Case No. ______________ (Chapter ______ ) APPLICATION FOR APPOINTMENT OF PRO BONO COUNSEL FOR A NON-DEBTOR PARTY IN A CONTESTED MATTER Part A. Family Size and Income. 1. Including yourself, your spouse, and dependents, how many people are in your family? (Do not include your spouse if you are separated.) __________________ 2. Complete Bankruptcy Schedule I (Official Form 6I) and restate the amount provided on Line 16. (Attach a completed copy of Schedule I with this application.) Total Combined Monthly Income (Line 16 Schedule I) 3. State the monthly net income, if any, of dependents included in Question 1 above. Do not include any income already reported in Question 2. If none, enter $0 4. Add lines 3 and 4. $_________________ $_________________ $_________________ Part B. Monthly Expenses. 5. Complete Bankruptcy Schedule J (Official Form 6J) and restate the amount provided on Line 18. (Attach a completed copy of Schedule J with this application.) Part C. Real and Personal Property. 6. State the amount of cash you have on hand. 7. State below any money you have in savings, checking, or other accounts in a bank or other financial institution. Bank or other Financial Institution: Type of Account (savings, checking, DC): Amount: $_____________________ $_____________________ $_____________________ $_________________ $_________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ American LegalNet, Inc. www.FormsWorkFlow.com 8. State the assets owned by you. Do not list ordinary household furnishings and clothing. Address: Home ______________________________________ ______________________________________ Address: Other real estate ______________________________________ ______________________________________ Motor Vehicle Model/Year: ___________________________ _____________________________________ Motor Vehicle Model/Year: ___________________________ _____________________________________ Other Description: ___________________________ _____________________________________ Value Amount owed: Value: Amount Owed: Value: Amount Owed: Value: Amount Owed: $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ Value: Amount owed: $____________________ $____________________ 9. State below any person, business, organization, or governmental unit that owes you money and the amount that is owed. Name of person, business, or organization that owes you money: __________________________________________ __________________________________________ Amount Owed $___________________ $___________________ Part D. Additional Information. 10. Please provide any other information that helps to explain why you are unable to afford counsel. 11. I declare under penalty of perjury that I cannot currently afford counsel in this matter and that the foregoing information is true and correct. Executed on: _________________ Date _______________________________________________ Signature American LegalNet, Inc. www.FormsWorkFlow.com