Whether the petitioner is entitled to proceed in forma pauperis

No question identified. : AFFIDAVIT OR DECLARATION IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS I, Samir Hanna _, am the petitioner in the above-entitled case. In support of my motion to proceed in forma pauperis, I state that because of my poverty I am unable to pay the costs of this case or to give security therefor; and I believe I am entitled to redress. 1. For both you and your spouse estimate the average amount of money received trom each of the following sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, 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 Amount expected the past 12 months next month You Spouse You Spouse Employment 3 DF s_b, $00 $__ @ $_Oy $00 Self-employment $_N {oe $_Nfo $ Ala ( $_Qlo Income from real property $f vo $I $_ nfo _ §$ D/a (suck as rental income} { Interest and dividends $ No $_nfo s nla s_nfa Gifts snfa shir svfo sola Alimon | mony sols sooo sinfa sna Child Support n/a ; pp snf/fa sna $s nia $ nye Retirement (such as social $hia $f HON $_ fas $_ D/C security, pensions, nfs annuities, insurance) Disability (such as social $Y UA $ O/a S$ Nilo $N Hex secunity, insurance payments} fo {6 Unemployment payments $ De $_N fa $ Alo $ N/a Public-assistance $a $nNig $Aia $f a 7 (such as welfare) 0 t Other (specify): v\/¢ $a s Qo $ A/a s nfo Total monthly income: $ 2 $_é, BfO $_ M$ Oy YOO 2. List your employment history for the past two years, most recent first. (Gross monthly pay is before taxes or other deductions.) Employer Address Dates of Gross monthly pay Employment ST ee — LS Se a a $e —— ——EE as S$ 3. List your spouse’s employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Address Dates of Gross monthly pay . . : : Employment Foothill fmnilyService_330 W.Bodillo _ feb 2004 $6, $00, = —— Coving.~AGyqZ2 a 4. How much cash do you and your spouse have? $ Below, state any money you or your spouse have in bank accounts or in any other financial institution. Type of account (e.g., checking or savings) Amount you have ane your spouse has eel es St Om Sang ep —i—— $ L900. es Ne FCG 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. OC Home ; C Other real estate Value av lon Value __{ Wier = C1] Motor Vehicle #1 _ O Motor Vehicle #2 Year, make & model Z0Q5 yofs Piclevales Year, make & model Z0/% Levus ES 250 Value Value __ _ U Other assets Description wef Value __— 6. State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or Amount owed to you Amount owed to your spouse your spouse money $f $F s sf 7. State the persons who rely on you or your spouse for support. For minor children, list initials instead of names (e.g. “J.S.” instead of “John Smith”). Name Relationship Age Sr a a ' 8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, or annually to show the monthlv rate. You Your spouse Rent or home-mortgage payment _ (include lot rented for mobile home) $ (a) $ _l, FOO. Are real estate taxes included? [() Yes RN Is property insurance included? (J Yes No Utilities (electricity, heating fuel, water, sewer, and telephone) $ 50. $. {4 ), = Home maintenance (repairs and upkeep) $ $_tao. — Food $_ — $400.7 Clothing $ $__ £0. — Laundry and dry-cleaning $ $ Medical and dental expenses $ 49. — $70) You Your spouse Transportation (not including motor vehicle payments) $120.~ g 1YO.Recreation, entertainment, newspapers, magazines, etc. $ __— $_ 340. _ Insurance (not deducted fom wages or included in mortgage payments) Homeowner’s or renter’s Ga, LO. Life $= GL Health $ = $347 .— Moto