(full name of plaintiff or petitioner)

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF ILLINOIS

APPLICATION TO PROCEED

WITHOUT PREPAYING FEES OR

COSTS / FINANCIAL AFFIDAVIT

(NON-PRTSONER CASE)

Case number:

K ,o proceed in forma pauperis (IFP) (without prepaying fees or costs)

X ,o request an attorney

L. Are you emplolted?

- 

Yes Name and address of employer:

Total amount of monthly take-home pay:

X No Date(s) of last employment,OflldA0il- Last monthly take-home Ourr{ \015,

2. lf married, is your spouse employed? N_Not married

Yes Name and address of spouse's employer:

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

_ No Date(s) of spouse's last employment: 

- 

Spouse's last monthly take-home Pay: 

-

3. Other sources of income / mone!!; For the past L2 months, list the amount of money that you and/or

your spouse have received from any of the following sources:

Self-employment, businessr 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:

(list the 12-month total for each)

$

$

$

$

$

$

$

$

$

a

nif Corrruission

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):

s) or respondent(s

Rev.2/2020

Page 1. of 2

o

FILED 3/31/2020

THOMAS G. BRUTON CLERK, U.S. DISTRICT COURT

20CV2111

Case: 1:20-cv-02111 Document #: 5 Filed: 03/31/20 Page 1 of 2 PageID #:111
Cash and bank accounts; Do you and/or your spouse have any money_in cash or in a checking or

savings account? X Y"r 

- 

No If yes, how much? - 

q-?

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

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

nl o n€-

No

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

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

xlorr€-

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

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.

6. Dependents: Is anyone dependent on you and,f or your spouse for support? 

- 

Yes * *"

Date: €13a1a0a0 ehc,nJ,rJil\ )>ona+-@

Lti't dl,/.:+l^ \TnLalez

Printed name

Proaide any other infonnation that will lrclp explain wlry ltou cannot afford to pay court fees / hire an attorney:

Rev.2/2020

Page2 of 2

Case: 1:20-cv-02111 Document #: 5 Filed: 03/31/20 Page 2 of 2 PageID #:112