McCarthy v. Ebbert et al

Filing 10

ORDER: In accord with the accompanying Memorandum 9 : Pltf's mtn to proceed ifp 8 is denied. The clerk shall provide pltf with a blank ifp form. Pltf shall complete the form within 14 days of the date of this order orsubmit the entire $400 filing fee. Failure to complete ifp form or submit payment within 14 days will resulty in termination of this case.Signed by Honorable William W. Caldwell on 5/23/17. (Attachments: # 1 IFP Form)(ma)

UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
_____________________________________________
(Plaintiff)
v.

AFFIDAVIT / DECLARATION
IN SUPPORT OF REQUEST
TO PROCEED
IN FORMA PAUPERIS

_____________________________________________
(Defendant)

I, _______________________________________certify that I am the plaintiff in the above
entitled case; that in support of my motion to proceed without being required to prepay fees,
costs or give security therefor, I state that because of my present financial condition I am unable
to pay the costs of said proceeding or to give security therefor; that I believe I am entitled to
redress.
I further state that the responses which I have made to questions and instructions below are true
and correct.
1.

Are you presently employed?

Yes _____

No _____

a. If the answer is yes, state the amount of your salary or wages per month, and give the name
and address of your employer.
__________________________________________________________________________
b. If the answer is no, state the date of last employment and the amount of the salary and wages
per month which you received.
__________________________________________________________________________

2. Have you received within the past twelve months any money from any of the following
sources?
a. Business, profession or form of self-employment?

Yes _____ No _____

b. Rent payments, interest or dividends?

Yes _____ No _____

c. Pensions, annuities or life insurance payments?

Yes _____ No _____

d. Gifts or inheritances?

Yes _____ No _____

e. Any other sources?

Yes _____ No _____

If the answer to any of the above is yes, describe each source of money and state the amount

received from each during the past twelve months.
____________________________________________________________________________
____________________________________________________________________________
3. Do you own any cash, or do you have money in a checking or savings account? Yes _____
No _____
(Include any funds in prison accounts.)
If the answer is yes, state the amount of cash or the present balance in any account.
____________________________________________________________________________
____________________________________________________________________________

4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property,
excluding ordinary household furnishings and clothing? Yes _____ No _____
If the answer is yes, describe the property and state its approximate value.
____________________________________________________________________________
____________________________________________________________________________

5. List the persons who are dependent upon you for support, state your relationship to those
persons, and indicate how much you contribute toward their support. In order to comply with the
court’s privacy policy, only the initials of a minor should be listed below. Also, listing the age of
the minor is acceptable; however, only the year of birth may be included. See the court’s “Notice
of Electronic Availability of Civil and Criminal Case File Information” and Local Rule 5.2 for
more information on redaction of personal data identifiers.
____________________________________________________________________________
____________________________________________________________________________

6.

List your monthly expenses for:
food
rent
utilities
child care
medical care
other (explain)

__________
__________
__________
__________
__________
__________

__________________________________________________________________________

7.

List any debts (mortgage, credit card, student loan, etc.) and the monthly fee on those debts:

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

I understand that a false statement or answer to any questions in this
affidavit/ unsworn declaration will subject me to penalties for
perjury.
I declare under penalty of perjury that the foregoing is true and
correct.

Executed on _____________________________
Date

______________________________
Signature of Plaintiff