UNITED STATES DISTRICT COURT

for the

Central District of Illinois

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Plaintiff(s)	)

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vs.	)	Case Number:

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Defendant(s)	)

MOTION TO REQUEST COUNSEL

1.	I, , declare that I am (check one)

□ Plaintiff	□ Defendant	in the above-entitled proceeding and state that I am

unable to afford the services of an attorney, and I request that the Court assist me in seeking volunteer counsel to represent me in this proceeding.

2.	In support of my motion, I declare that I have contacted the following attorneys/organizations seeking representation in this case: (This item must be completed, and you should attach documentation showing that you have asked several attorneys to represent you in this case.)

3.	In further support of my motion, I declare that (check appropriate box):

□	I am not currently, nor previously have been represented by an attorney appointed by the Court in this or any other civil or criminal proceeding before this Court.

□	I am currently, or previously have been, represented by an attorney appointed by this Court in the proceeding(s) described on the back of this page.

4.	In further support of my motion, I declare that (check appropriate box):

□	I have attached an original Application to Proceed In Forma Pauperis detailing my financial status.

□	I have previously filed an Application to Proceed In Forma Pauperis in this proceeding and it is a true and correct representation of my financial status.

4.	(continued)

□	I have previously filed an Application to Proceed In Forma Pauperis in this proceeding; however, my financial status has changed and I have attached an amended Application to Proceed In Forma Pauperis to reflect my current financial status.

5.	In further support of my motion, I declare that my highest level of education is (check one):

□ Grammar school only	□ Some high school	□ High School graduate

□ Some college	□ College graduate	□ Post-graduate

6.	(Check only if applicable): □ In further support of my motion, I declare that my ability to speak, write, and/or read English is limited, because English is not my primary language or because (explain reason):

7.	I declare under penalty of perjury that the foregoing is true and correct.

Date:

Movant's Signature

Street Address

City/State/Zip

Failure to complete all items in this form may result in the denial of this motion.