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Rev. 2/2020 

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF ILLINOIS

APPLICATION TO PROCEED 

WITHOUT PREPAYING FEES OR 

COSTS / FINANCIAL AFFIDAVIT 

(NON-PRISONER CASE) 

Case number: 

(full name of plaintiff or petitioner) 

vs.

(full name of defendant(s) or respondent(s)) 

Instructions: Please answer every question. Do not leave blanks. 

If the answer is "0" or "none," say so.

Application: I am one of the parties in this case. I believe that I am entitled to the relief I am 

requesting in this case. I am providing the following information under penalty of perjury in support of 

my request (check all that apply): 

___ to proceed in forma pauperis (IFP) (without prepaying fees or costs) 

___ to request an attorney 

1. Are you employed?

___ Yes Name and address of employer: __________________________________________________ 

Total amount of monthly take-home pay: __________________________________________ 

___ No Date(s) of last employment: _____________ Last monthly take-home pay:______________ 

2. If married, is your spouse employed? ____ Not married

___ Yes 

___ No 

Name and address of spouse's employer: __________________________________________ 

Total amount of spouse's monthly take-home pay: __________________________________ 

Date(s) of spouse's last employment: Spouse's last monthly take-home pay: 

3. Other sources of income / money: For the past 12 months, list the amount of money that you and/or

your spouse have received from any of the following sources:

 (list the 12-month total for each) 

Self-employment, business, or profession: $ _________________________ 

Income from interest or dividends: $ _________________________ 

Income from rent payments: $ _________________________ 

Pensions, annuities, or life insurance: $ _________________________ 

Disability or worker's compensation: $ _________________________ 

Gifts (including deposits into any accounts in your name): $ _________________________ 

Unemployment, public assistance, or welfare: $ _________________________ 

Settlements or judgments (include any that are expected): $ _________________________ 

Any other source of money: $ _________________________

Timothy Kendrick

City of Chicago; Offcs. Lupo & Hunt

2019 $450

2018 $400

$9,420

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Case: 1:20-cv-03871 Document #: 4 Filed: 07/01/20 Page 1 of 2 PageID #:13
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Rev. 2/2020 

4. Cash and bank accounts: Do you and/or your spouse have any money in cash or in a checking or

savings account? ___ Yes ___ No If yes, how much? ______________________________________

5. Other assets: Do you and/or your spouse own or have an interest in any real estate (including your

home), stocks, bonds, other securities, retirement plans, automobiles, jewelry, or other valuable

property (not including ordinary household furnishings and clothing)? ___ Yes ___ No

If yes, list each item of property and state its approximate value:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

6. Dependents: Is anyone dependent on you and/or your spouse for support? ___ Yes ___ No

If yes, please list their names (for minor children, use only initials); relationship to you; and how

much you and/or your spouse contribute toward their support each month:

_________________________________________________________________________________________

_________________________________________________________________________________________

7. Debts and financial obligations: List any amounts you owe to others:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

8. Provide any other information that will help explain why you cannot afford to pay court fees / hire an attorney:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Declaration: I declare under penalty of perjury that all of the information listed above is true and correct. 

I understand that a false statement may result in dismissal of my claims or other sanctions. 

Date: ____________ __________________________________________ 

Applicant's signature 

_________________________________________ 

Printed name 

7 minor children: T.M.K.; T.M.C.; B.C.; D.C.; M.C.; M.C.; K.Y. $300/month for all minor children.

No other dependents. 

$371/month payments towards a vehicle

$111/month for rent

Approximately $1,300 is currently owed on Gas (overdue); $3,000 owed in electric (overdue)

Mr. Kendrick was shot in the chest when he was 15 years old and is currently 41. He cannot work

consistently and relies on disability payments and support (physical and financial) from family.

06/10/20

Timothy Kendrick

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/s/ Timothy Kendrick

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