Whether the petitioner's affidavit or declaration in support of motion for leave to proceed in forma pauperis is sufficient to establish poverty and entitlement to redress

No question identified. : AFFIDAVIT OR DECLARATION IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS T, SeRemy L, DALE , 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 from 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 $ N/A 7 g_N/ _ ta s_N/A__ sN/A Self-employment g_N | A s_NjA sl /A_ s_NiA income from real property s_N/ A s_N/A sho /A_ sina (such as rental income) Interest and dividends ¢_N | A s_N/A_ sj A s_w/H Gifts sW/A_ s_n/A_ sIW/A_ s_q/A__ Alimony s_W/A 5 W/d sNIA suit Child Support s_N/A_ s_N{A_ sdf A sil Retirement (such as social s NEAL s_ NM $ A $ security, pensions, Se NA annuities, insurance) Disability (such as social $ s_N fA gs / A s_N/A security, insurance payments) . Unemployment payments s NA s/h sW/ A s NA Public-assistance s_ Ny h s_N (A sy) A s_N HA (such as welfare) Other (specify): Riel g_ Sd s N/A sf s N/A Total monthly income: $ NI A sW/A sN (A s N/A 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 L| $ 7 —Wfts __ WA Sw 8. 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 : N/A w/A N A $ W/ WL is $_iv/4 ; Wy Pe Ww, BO it th _ $iw/A _ 4, How much cash do you and your spouse have? gf 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) amaunt ou have Amount your spouse has | " $ $ wJ $_ NA $ WIA 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. OlHome | CO Other real otk Value NA Value Wf O Motor Vehicle #1 ft (Motor Vehicle #2 4) , Year, make & model w/t Year, make & model NAY Value__N /f_ Value W/Ae . O Other assets , Description SNR Value _—Nijfe \ ‘ 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 . _ N/A $s fboff s_w/A — W/R s_w/A i 7. State the persons who rely on you or your spouse for support. For minor children, list initials instead of names @.g. “J.S.” instead of “John Smith”). Name Relationship Age — N/A fA NA wey W/W ; 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 monthly rate. You Your spouse Rent or home-mortgage payment . Ny A (include lot rented for mobile home) s NA s_N/h Are real estate taxes included? [1 Yes who Is property insurance included? OlYes [No _ Utilities Clectricity, heating fuel, water, sewer, and telephone) s U/A_ s P/N Home maintenance (repairs and upkeep) s_W/A sW [A Food s_W/A_ sf Clothing anves se Laundry and dry-cleaning s/h s_N/A Medical and dental expenses s WA s W/O | . You Your spouse Transportation (not including motor vehicle payments) ¢ N/A s_V/A Recreation, entertainment, newspapers, magazines, ete. $ NY A sw Insurance (not deducted from wages or included in mortgage payments) Homeowner’s or renter’s sa s_ vA Life sN/A s_vj/A Health s N/A s_W/A , Motor Vehicle s N/A s_WjA_ othe; — N/R og NK g yh Ta