Whether the petitioner's affidavit or declaration in support of a motion for leave to proceed in forma pauperis is sufficient to establish their inability to pay the costs of the case

No question identified. : | | | [AFFIDAVIT OR DECLARATION ‘ IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IW FORMA PAUPERIS as L a ohh Xk AN QA, , am the petitioner in the above-entitled case, In support of ; my motion to proceed in Lerma. pauperis, L state that because of my poverty Tam unable to pay the costs of this case orto give security *herefor;.and{] believé T ain entitled to Fours, ie aah MOY Ayer “hekaan& Nemoual be. (= wee Ny ICATE, dy KNOW AE Oa Mea & Aerial, Gar \ 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 p Spouse , . You Spouse Employment $ Ww ye $ a $ Me i $_ RS ty Self-employment Siv gtr g 7 i g_he if. Sie ie : Income from real Property $ \y | h. $ (2) ! & $ u i f $ A f f _ (such as rental income) , 7 7 Interest and dividends $ Is fy g__ ly pb $ lv ih $ fy ip ; Gifts Woy Mh hak Ho ty fA Alimony Sith si gin le og a ea . “ ry : ip f i A 24 ta vA i Child Support Soh g fee is $e! eg gh Retirement (such as social $ i it $ | iH g_it VP $_ iA ae Secutity, pensions, . annuities, insurance) , Disability (such as social $ NN a $. fA) ie g_it i she security, insurance payments) . i Unemployment payments gf : Me g_ fh tA gb gt I * ‘Public-assistance $ i ul $ ut | ut git | af $_ if I 2 a yt. ! bi 4 & ibe fs, (such as welfare) i A +: | ; ~ + = Other (specify): Moe sg gn ga uA Total monthly income: $i tg per gy The gob i ' , 2. List your employment history for the past two years, most recent first. (Gross monthly pay ; 18 before taxes or other deductions.) Employer Address Dates of Gross monthly pay . f al Emplayment, iif, a Vote J a Wes I slg 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 ‘ ad at fi Employment i . _ Bip ul Eee sia — a [eet i hd $ wy th { : : i f ' 4, How much cash do you and your spouse have? $ y, \ A . ' Below, state any money you or your spouse have in bank accounts or in any other financial : : institution, Financial j Stitution Type of account Amoun you have Amount yo t spouse has 5, List the assets, and their values, which you own or your spouse owns, Do not list clothing — / andordinary household furnishings, ; af ° f ; Ef Home A } Other real estate . Je fp. F 7 A. : . Value bs Value __ Ay fé ee ; é | Motor Vehicle #1 , He ; Motor Vehicle #2 ite Year, make & morlel iM tie Year, make & model hi ih _ Other assets af i A Description 7 ee ee e . OO Value Mey __ ; AO . ' 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 spo is money i. i j . Ww 1 iy $ wv iM $ iv ila i 7, State the persons who rely oh you or your spouse for support. ° | aName j Relationship Age | i } k F 4 A fo ME oe wari Na bie , p—— Mis Ie wT i ; | 8. Estimate the average monthly expenses of you and your family, Show separately the amounts . og 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 A ja. f } a. "(include lot rented for mobile home) $ te $. I Ag Are real estate taxes included?) OYes ON ° Is property insurance included? OYes ONo : Utilities (electricity, heating fuel, fg | a gl La water, sewer, and telephone) § AL Re F fy [BS Home maintenance (repairs and upkeep) $ ( i | ra $ ii \ J a we , ; Clothing ‘ ly V3 is 4. Laundry ing” ly ie Ree aundry and dry-cleaning : $_ re $ ha fess ‘ i. A Medical and dental expenses | $ hil 4 ‘g Ww i ie Sp “ : 7 ,