Application To Proceed In Forma Pauperis With Supporting Documentation

IN THE UNITED STATES DISTRICT COURT EASTERN DISTRICT OF TENNESSEE ) ) v. ) NO. ) ) APPLICATION TO PROCEED IN FORMA PAUPERIS WITH SUPPORTING DOCUMENTATION YOUR EMPLOYMENT AND INCOME DATA 1. NAME (First Middle Last) 2. BIRTH DATE (mo day yr) 3. SOCIAL SECURITY NO. 4. PHONE NOS. - - 5. HOME ADDRESS: 6. HOW LONG AT CURRENT ADDRESS? 7. OWN OR RENT? 8. NAME AND ADDRESS OF CURRENT EMPLOYER: 9. TELEPHONE NUMBER OF EMPLOYER: 10. HOW LONG AT CURRENT EMPLOYMENT? 11. OCCUPATION (Describe what you do): 12. IF NOT CURRENTLY EMPLOYED, GIVE MONTH AND YEAR OF LAST EMPLOYMENT: <<<<<<<<<********>>>>>>>>>>>>> 2 2 13. CURRENT MONTHLY INCOME Salary or Wages $ Commissions $ All Other Sources (Pensions, Soc. Sec., Rent, Interest, Dividends, Alimony, etc.): $ __________________ TOTAL $ SPOUSES EMPLOYMENT AND INCOME DATA 1. NAME: 2. BIRTH DATE (mo day yr) 3. SOCIAL SECURITY NO. 4. PHONE NOS. - - 5. HOME ADDRESS: (if different from yours) 6. HOW LONG AT CURRENT ADDRESS? 7. NAME AND ADDRESS OF CURRENT EMPLOYER: 8. TELEPHONE NUMBER OF EMPLOYER: 9. HOW LONG AT CURRENT EMPLOYMENT? 10. OCCUPATION (Describe what you do): 11. IF NOT CURRENTLY EMPLOYED, GIVE MONTH AND YEAR OF LAST EMPLOYMENT: <<<<<<<<<********>>>>>>>>>>>>> 3 3 12. SPOUSES CURRENT MONTHLY INCOME Salary or Wages $ Commissions $ All Other Sources (Pensions, Soc. Sec., Rent, Interest, Dividends, Alimony, etc.): $ __________________ TOTAL $ NAME OF DEPENDENTS AND INCOME (if any) Names: Age: Relationship: Living With Whom?_____________________________ ________ ___________________ __________________________________________ ________ ___________________ __________________________________________ ________ ___________________ __________________________________________ ________ ___________________ __________________________________________ ________ ___________________ __________________________________________ ________ ___________________ _____________ TOTAL MONTHLY INCOME OF DEPENDENTS INCLUDING CHILD SUPPORT PAYMENTS (exclude spouse) $ TOTAL MONTHLY INCOME OF APPLICANT, SPOUSE, AND DEPENDENTS $ <<<<<<<<<********>>>>>>>>>>>>> 4 4 ASSETS: CASH $ CHECKING ACCOUNTS--TOTAL BALANCE (List Banks Below) $ _________________________________ _________________________________ _________________________________ SAVINGS ACCOUNTS--TOTAL BALANCE (List Banks Below) $ _________________________________ _________________________________ _________________________________ STOCKS AND BONDS $ REAL ESTATE--CURRENT FAIR MARKET VALUE (List Locations Below) $ $ $ TOTAL REAL ESTATE $ VALUE OF PERSONAL PROPERTY, EXCLUDING VEHICLES (Itemize) $ $ $ $ TOTAL PERSONAL PROPERTY $ MOTOR VEHICLES <<<<<<<<<********>>>>>>>>>>>>> 5 5 Year/Make License No. Current Value $ $ $ $ TOTAL VALUE OF MOTOR VEHICLES $DEBTS OWED TO YOU (Give Name of Debtor) $ $ TOTAL DEBTS OWED TO YOU $OTHER ASSETS (ITEMIZE) $ $ $ TOTAL OTHER ASSETS $ TOTAL ASSETS $ <<<<<<<<<********>>>>>>>>>>>>> 6 6 LIABILITIES: NOTES (LOANS) PAYABLE TO BANKS (List Banks and Amount of Loans) $ $ $ TOTAL LOANS PAYABLE TO BANKS $ NOTES (LOANS) PAYABLE TO OTHERS $ MORTGAGES PAYABLE ON REAL ESTATE $ CREDIT CARDS AND ACCOUNTS PAYABLE TO CREDITORS $ MEDICAL BILLS $ TAXES AND ASSESSMENTS PAYABLE $ OTHER LIABILITIES (Itemize) $ $ $ TOTAL LIABILITIES $ <<<<<<<<<********>>>>>>>>>>>>> 7 7 LIVING EXPENSES: Monthly Payment Balance Owing RENT or MORTGAGE PAYMENT (Indicate Which) $ $ UTILITIES a. Electricity $ $ b. Water $ $ c. Gas $ $ d. Telephone $ $ e. Other $ $ FOOD $ $ ALIMONY $ $ CHILD SUPPORT $ $ CHILD CARE $ $ SCHOOL EXPENSES $ $ AUTOMOBILE NOTE $ $ AUTOMOBILE INSURANCE $ $ AUTOMOBILE REPAIRS $ $ GASOLINE $ $ FURNITURE NOTE $ $ CLOTHING $ $ CABLE TELEVISION $ $ LIFE INSURANCE $ $ HOSPITALIZATION INSURANCE $ $ DOCTORS $ $ DRUGS $ $ CREDIT CARDS (LIST/MONTHLY PAYMENTS) $ $ $ $ $ $ OTHER CHARGE ACCOUNTS OR CREDITORS $ $ TAXES $ $ ANY OTHER DEBTS (LIST) $ $ $ $ $ $ $ $ TOTAL EXPENSES $ <<<<<<<<<********>>>>>>>>>>>>> 8 8I hereby certify that the above statement is true and that it is a complete statement of all my income and assets, real andpersonal, whether held in my name or by any other, under penalty of perjury. Date Signature