You're viewing Docket Item 2.1 from the case Karron v. United States of America. View the full docket and case details.

Download this document:




Case 1:12-cv-04521-LAP Document 2-1 Filed 07/25/12 Page 1 of 2

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF NEW YORK

_______________________________________________
_______________________________________________
(In the space above enter the full name(s) of the plaintiff(s)/petitioner(s).)

-against-

_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
(In the space above enter the full name(s) of the defendant(s)/respondent(s).)

___ Civ. ______ (___) (___)

REQUEST TO PROCEED
IN FORMA PAUPERIS

I, _____________________________________, (print or type your name) am the plaintiff/petitioner in the
above entitled case and I hereby request to proceed in forma pauperis and without being required to prepay
fees or costs or give security. I state that because of my poverty I am unable to pay the costs of said
proceeding or to give security therefor, and that I believe I am entitled to redress.

1.

If you are presently employed:

a) give the name and address of your employer
b) state the amount of your earnings per month

________________________________________________________________________

________________________________________________________________________

2.

If you are NOT PRESENTLY EMPLOYED:

a) state the date of start and termination of your last employment
b) state your earnings per month

YOU MUST ANSWER THIS QUESTION EVEN IF YOU ARE INCARCERATED.

________________________________________________________________________

3.

Have you received, within the past twelve months, any money from any source? If so, name the
source and the amount of money you received.

________________________________________________________________________

a) Are you receiving any public benefits?

G No. G Yes, $_________.

b) Do you receive any income from any other source? G No.

G Yes, $_________.

Rev. 05/2010

1

Case 1:12-cv-04521-LAP Document 2-1 Filed 07/25/12 Page 2 of 2

4.

Do you have any money, including any money in a checking or savings account? If so, how much?

G No.

G Yes, $__________.

5.

Do you own any apartment, house, or building, stock, bonds, notes, automobiles or other property?
If the answer is yes, describe the property and state its approximate value.

G No.

G Yes, $ ____________________________________________________.

6.

Do you pay for rent or for a mortgage? If so, how much each month?

G No.

G Yes, ____________.

7.

List the person(s) that you pay money to support and the amount you pay each month.

_____________________________________________________________________________

_____________________________________________________________________________

8.

State any special financial circumstances which the Court should consider.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

I understand that the Court shall dismiss this case if I give a false answer to any questions in this
declaration.

I declare under penalty of perjury that the foregoing is true and correct.

Signed this __________ day of __________________, ______.



date

month

year

____________________________________

Signature

Rev. 05/2010

2