Step 3: Affidavit of Indigency

Important Note: This is the most “sensitive” page. You will need to fill in the numbers in the brackets [ ]. This is the specific page you must sign in front of a Notary Public so they can witness your signature and stamp it.

I, ______________________ being first duly sworn, depose and say that I am the Amicus Curiae, Pro Se in the above-entitled case; that in support of my motion to proceed in forma pauperis, I state that because of my poverty I am unable to pay the docket fees of this case or to give security therefor; and I believe I am entitled to redress.

1. MARITAL STATUS: Separated
2. MONTHLY INCOME: My take-home pay is approximately is Social Security of $1100 monthly.

Total expenses: phone, automobile payments, auto insurance, healthcare items, and nourishment.]

5. DEPENDENTS: I have NO dependents relying on me for support.

I declare under penalty of perjury that the foregoing is true and correct. I further declare that I am a descendant of America’s chattel slaves and am filing this brief in the primary interest of the federal citizenship status guaranteed by the 1866 Civil Rights Act.

Executed on this ___th day of March, 2026.

Subscribed and sworn to (or affirmed) before me this _______ day of March, 2026, by ___________________, who proved to me on the basis of satisfactory evidence to be the person who appeared before me.

NOTARY PUBLIC
(Seal)