Whether the petitioner is entitled to proceed in forma pauperis

No question identified. : t ‘ \ , , AFFIDAVIT OR DECLARATION : IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS — , Demedrivs Wi oe I, \ f tkson , 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 sQ_ $ sQ <Q Self-employment — $ $ $ ae Income from real property $ $ $ $ oN (such as rental income) Q Interest and dividends sQ $ $ Qe Gifts $ sO $ s SQ Alimony $ $ $_— iQ Child Support $ $ ae gs Retirement (such as social — XQ $ $ s\ security, pensions, annuities, insurance) Q “ ay Disability (such as social $_ sQ $ $A security, insurance payments) \ Public-assistance s Q_ $ $ $_ (such as welfare) Q aN Cy Other (specify); HN XQ. $ NG Total monthly income: sw ~Q_ OQ Su 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 . $ $ A. $ 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 . $ $ $ 4. How much cash do you and your spouse have? $. < \. Below, state any money you or your spouse have in bank acéounts or in any other financial institution. : Type of account (e.g., checking or savings) Amount you have Amount your spouse has $ $ : _ § $ $ __ §$ | : 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. 0 Home CI Other real estat Value NA, Value NY Cl Motor Vehicle #1 N A (Motor Vehicle #2 Year, make & model /V "N Year, make & model Value | Value O Other assets : Description. ; 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 . $ ; $ s | s_/\| 4 $ s_[ VI 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 A\_ fh NE /\ | j\| v 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 ; C ) (include lot rented for mobile home) $ : $ Ne Are real estate taxes included? [1 Yes CINo Is property insurance included? 01 Yes ONo Utilities electricity, heating fuel, ; water, sewer, and telephone) $. : $ Home maintenance (repairs and upkeep) $ $ Food : $ Z $ Clothing ; $ $ KX Laundry and dry-cleaning — Q— S_ Medical and dental expenses ; © XQ You Your spouse Transportation (not including motor vehicle payments) §. $ . N Recreation, entertainment, newspapers, magazines, etc. <Q $. Insurance (not deducted from wages or included in mortgage payments) ; Homeowner’s or renter’s ; _ Se . Life $ = $ Health -Q_ sQ Motor Vehicle . sQ_ _S Other: s,Q. sQ Taxes (not deducted from wages or included in mortgage payments) . pecify); s QQ gs) Installment payments ; _ : Motor Vehicle $ QO s) Credit card(s) gs LY sC\ Department store(s) gs SY sQ Other; s SS sO Alimony, maintenance, and support paid to others s VO 3 SS Regular expenses for operation of business, professio