United States District Court Western District of Kentucky

, Plaintiff
v.
, Defendant(s)
If you do not know your case number, please obtain it from the Clerk before continuing. You may ONLY leave this section blank if you are filing a civil complaint form alongside this application.
CASE NUMBER:
I am filing this alongside a civil complaint

I, , swear or affirm under penalty of perjury that I am the (check appropriate box)

in the above-named proceeding, that I am unable to pay the costs of these proceedings, and that I believe I am entitled to the
relief sought in the complaint/petition/motion. I further swear or affirm under penalty of perjury under United States laws that
my answers on this form and any attachments are true and correct.

Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is "0", "none",
or "not applicable (N/A)," write in that response. If you need more space to answer a question or to explain your answer,
attach a separate sheet of paper identified with your name and the question number.

NOTE: You should be prepared to provide the Court with copies of documents that support or verify all your
answers to the questions in this application.

Signed:
Clear Signature

Print your Name:
Date:

1. State the address of your legal residence.

Address Street and Number:
Address City, State, and ZIP:
Daytime Phone Number:

2. For both you and your spouse, estimate the average amount of money received from each of the following sources
during the past 12 months. Adjust any amount that was received weekly, bi-weekly, quarterly, semi-annually, or
annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise.

Income Source	Average monthly amount during the past 12 months		Amount expected next month
	YOU	SPOUSE	YOU	SPOUSE
Employment	$	$	$	$
Self-employment	$	$	$	$
Income from real property (such as rental income)	$	$	$	$
Interest & dividends	$	$	$	$
Gifts or Inheritance	$	$	$	$
Alimony	$	$	$	$
Child support	$	$	$	$
Retirement (e.g. social security, pensions, annuities, insurance)	$	$	$	$
Disability (e.g. social security, insurance payments)	$	$	$	$
Unemployment payments	$	$	$	$
Public assistance (e.g. welfare)	$	$	$	$
Other (specify):	$	$	$	$
Total Monthly Income	$	$	$	$

3. Are you currently employed?
Is your spouse currently employed?

4. List your employment history, current or, if you are not currently employed, most recent employer first. (Gross monthly
pay is before taxes or other deductions.)

	Employer	Address	Dates of Employment	Gross Monthly Pay
a.				$
b.				$
c.				$

5. List your spouse’s employment history, current or, if your spouse is not currently employed, most recent employer
first. (Gross monthly pay is before taxes or other deductions.)

	Employer	Address	Dates of Employment	Gross Monthly Pay
a.				$
b.				$
c.				$

6. How much cash do you and your spouse have?

Below, state any money you or your spouse have in checking or savings accounts or in any other financial institution.

	Financial Institution	Type of Account	Amount You Have	Amount Your Spouse Has
a.			$	$
b.			$	$
c.			$	$

7. List the assets, and their values, that you own or your spouse owns. Do not list clothing and ordinary household furnishings.

Asset	Description	Value
a. Home		$
b. Real Estate		$
c. Motor Vehicle	Make & Year: Model: License Plate #:	$
d. Motor Vehicle	Make & Year: Model: License Plate #:	$
e. Other Assets (e.g. stocks, bonds, securities, or other financial instruments)		$
f. Other Assets		$

8. State every person, business, or organization owing you or your spouse money, and the amount owed.

	Who owes you or your spouse money?	Amount owed to you	Amount owed to your spouse
a.		$	$
b.		$	$
c.		$	$
d.		$	$

9. State the persons who rely on you or your spouse for support. Use only initials for minors (under 18).

	Name	Relationship	Age	Amount Contributed Monthly for His/Her Support
a.				$
b.				$
c.				$
d.				$

10. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse.
Adjust any amount that was received weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly
rate.

Expense	You	Your Spouse
Rent or home mortgage payment (include lot rented for mobile home)	$	$
Are real estate taxes included? Yes No
Is property insurance included? Yes No
Utilities (electricity, heating fuel, water, sewer, telephone)	$	$
Home maintenance (repairs and upkeep)	$	$
Food	$	$
Clothing	$	$
Laundry and dry cleaning	$	$
Medical and dental expenses	$	$
Transportation (not including motor vehicle payments)	$	$
Recreation, entertainment, newspapers, magazines, etc.	$	$
Insurance (not deducted from wages or included in mortgage payments:
Homeowner's or Renter's	$	$
Life	$	$
Health	$	$
Motor Vehicle	$	$
Other	$	$
Taxes (not deducted from wages or included in mortgage payments) (specify):	$	$
Installment Payments:
Motor Vehicle	$	$
Credit Card(s) (name):	$	$
Department Store (name):	$	$
Other:	$	$
Alimony, maintenance, and support paid to others	$	$
Regular expenses for the operation of business, profession, or farm (attach detailed statement)	$	$
Other (specify)	$	$
TOTAL MONTHLY EXPENSES	$	$

11. Do you expect any major changes to your or your spouse’s monthly income or expenses, or in your or your spouse’s assets or liabilities during the next 12 months?

If yes, please describe.

12. Have you paid – or will you be paying – an attorney any money for services in connection with this case, including the completion of this form? If yes, how much? $

If yes, state the attorney's name, address, and telephone number:

13. Have you paid – or will you be paying – anyone other than an attorney (such as a paralegal or typist) any money for services with this case, including the completion of this form? If yes, how much? $

If yes, state the person's name, address, and telephone number:

14. Provide any other information that will help explain why you cannot, or cannot without undue hardship, pay the fees or costs for this case.