NO.

_________________________

IN THE DISTRICT COURT

JUDICIAL DISTRICT [PLAINTIFF(S)] AND STATE

[DEFENDANT(S)]

PRO SE PLEADING FORM

The Defendant (s) Plaintiff(s) request(s) to start/defend the aforementioned court case number on partial payment or waived court fees, with the express understanding, under oath and the knowledge that a false statement made in the following affidavit is perjury and punishable by to years in prison, that: 1. 2. 3. 4. I believe that I am entitled to the amount of relief requested: The type of action suit is: and I have not previously brought the claim before a similar court for similar purposes or due to similar evidences. I am unable to pay a partial portion of my court fees at this time, and have attached an affidavit providing a list of my assets, liabilities and income. I understand that I may still be required to pay percentages of court costs and additional fees mandated by the court. Personal Information Last Name: Maiden Name: Date of Birth: U.S Citizen: SSN: Address: Phone Number: Cell Number: First: / Yes No / Middle: Other Names:

Place of Birth: If No, Country of Citizenship: Drivers License: Work Number: Email Address: Position Title: per month per year

Employed? Y N Employment Name: Employment Address: Income: $ per week

Spouse Information Last Name: Maiden Name: Date of Birth: U.S Citizen: SSN: Address: First: / Yes No / Middle: Other Names:

Place of Birth: If No, Country of Citizenship: Drivers License:

Phone Number: Cell Number: Employed? Y N Employment Name: Employment Address: Income: $ per week

Work Number: Email Address: Position Title: per month per year

Children/Dependents Full Name 1. 2. 3. 4. 5. 6. 7. Address (if different) Relationship $ $ $ $ $ $ $ Support Received Minor?

Type Property Property Property Property Savings Account Checking Account Stocks/Bonds Mutual Funds Insurance Insurance Retirement Plan Retirement Plan Inheritance Inheritance Vehicle Vehicle Vehicle Furniture Furniture Furniture Electronics Electronics Electronics Apparel Apparel Jewelry Jewelry Antiques Household Goods Livestock

Assets Description $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Value

Monthly Expenses Mortgage Gas Electric Water/Sewer Telephone Cable/Internet Food Clothing Cleaning/Remodeling Car Payment Auto Insurance Gas Bus/Train/Cab Child Support Medical Insurance Tuition Credit Card Loans Other: Other: Is there money that you can borrow? Is there money that you are owed? Were you issued a refund on your tax return? Yes Yes Yes No No No If yes, how much? If yes, how much? If yes, how much? $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Cost

I hereby declare the aforementioned information to be true, factual and correct according to my knowledge and belief. Printed Name Date Signature

Sworn and Subscribed to Before Me: Public Notary My Commission Expires the day of 20