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No question identified. : AFFIDAVIT OR DECLARATION IN SUPPORT OF MOTION FOR LEAVE TO PROCEED JN FORMA PAUPERIS I, Michael! Or lega , 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 $_0.0 g_0.0_ $_0.0 $_ 0.0 __ Self-employment 3_ 0.0 $ 0-0 $ 0 0 — §$ 0. 0 : Income from real property $ 0.0 $ 0. 0 $ 0. 0 $ 0.( 0 (such as rental income) ; Interest and dividends $ 0.0 g_0. 0 $_ 0.0 $ 0 0 Gifts s 00 5s 00 5 00 5 00 Alimony s 00 5 00 5 00 5 00 Child Support g 0.0_ s_0.0_ ¢ 0.6 s 0.0 Retirement (such as social $ 0.0 $ 0.0 = s_0.0_ $ 0.0 security, pensions, annuities, insurance) Disability (such as social ¢_0.0 s_ 0.0 _ g_0.0 30.0 | security, insurance payments) Unemployment payments g_0.0 _ s_0.0 g_0.0 s_ 0.0 _ Public-assistance g 0.0 __ g_ 0.0 30.0 _ 5 0.0 (such as welfare) Other (specify); s__0.0_ s_ 0.0 _ s_ 0.0 _ 30.0 — Total monthly income: $ 0. 0 $ 0 O 50.0 s_0.0_ 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 wih NWS WIA s__0.0 Ni Nik NIA $ 0.0 —NiRK = NR CNA te SD 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 NYIN NIA Nai s 6.0 — Nik NTR IN Rg FD —NIR NA Ng 4. How much cash do you and your spouse have? $e 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) qnount ygu have Smouns your spouse has N/K : $0.0 SS OS 3h ———__Njk GDL FF : 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. (C Home L Other real estate Value O00 Value 00 O Motor Vehicle #1 LJ Motor Vehicle #2 Year, make & model NfK Year, make & model w/ A Value 0.0 Value__00 C Other assets Description ILS Value 0.0 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 BIA g___0.0 $ 0.0 NIA gs 0.0 gs 0.0 N/K s__ 0.0 gs O00 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 Michael Shegany Werrera Davqhtec 10 Nelson Poro2 Son Jo Kimberly Verrera Daughtec Q 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 () 0 (include lot rented for mobile home) g 0.0 a Are real estate taxes included? OYes CINo Is property insurance included? Yes ONo Utilities €lectricity, heating fuel, 0) ) 0 0 water, sewer, and telephone) S$. Mew Home maintenance (repairs and upkeep) $ 0.0 $ _ 0. 0 = Food gs 00 5 00 Clothing gs 0.0 0 ¢ 0.0 0 Laundry and dry-cleaning $ 0. 0 3s 0.0 0 . Medical and dental expenses $ 0 : 0) 5 0. 0 You Your spouse Transportation (not including motor vehicle payments) $ Q0 $ 0. 0 Recreation, entertainment, newspapers, magazines, ete. $ 0. 0 $ 0. 0 Insurance (not deducted from wages or included in mor