UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
CASE NUMBER
PLAINTIFF/PETITIONER
V.
REQUEST TO PROCEED IN FORMA PAUPERIS WITH
DECLARATION IN SUPPORT
DEFENDANT/RESPONDENT
I, declare under penalty of perjury, that the foregoing is true and
correct; that I am the petitioner/plaintiff in the above entitled case; that in support of my motion to proceed without
being required to prepay fees, costs or give security therefore, I state that because of my poverty I am unable to pay
the costs of said proceedings or to give security therefore and that I am entitled to redress.
I further declare under penalty of perjury that the responses which I have made to the questions and instructions
below are true, correct and complete.
1. Are you currently 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?
Public benefits? Yes No
Business, profession or form of self-employment? Yes No
Rent payments, interest or dividends? Yes No
Pensions, annuities or life insurance payments? Yes No
Gifts or inheritances? Yes No
Any other income (other than listed above)? Yes No
Loans? Yes No
Any other income (other than listed above)? Yes No
If the answer to any of the above is yes, describe such source of money and state the amount received from
each source during the past twelve (12) months:
CV-60 (11/23) REQUEST TO PROCEED IN FORMA PAUPERIS WITH DECLARATION IN SUPPORT Page 1 of 2
3. Do you own any cash, or do you have money in a checking or savings account? (include any funds in prison
accounts, if applicable) Yes No
If the answer is yes, identify each account and separately state the amount of money in each account for
each of the six (6) months prior to the date of this declaration.
4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary
household furnishings and clothing)? Yes No
If you answer is yes, describe the property and state its approximate value:
5. In what year did you last file an Income Tax Return?
Approximately how much income did your last return reflect?
6. 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:
7. Estimate your average monthly expenses below:
Housing Credit Cards
Transportation Child Care
Food Insurance
Medical Loans
Utilities Other
State County (or City)
I, declare under penalty of perjury that the foregoing is
true and correct. Executed on:
Date Plaintiff (Signature)
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