Whether the petitioner's constitutional rights were violated

No question identified. : No. ee IN THE SUPREME COURT OF THE UNITED STATES Erancette.L (Your Name) ; VS. UnraiiaatreeEs.Al — RESPONDENT(S) MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS The petitioner asks leave to file the attached petition for a writ of certiorari without prepayment of costs and to proceed in forma pauperis. Please check the appropriate boxes: a i Petitioner has previously been granted leave to proceed in forma pauperis in the following court(s): C) Petitioner has not previously been granted leave to proceed in forma pauperis in any other court. Petitioner's affidavit or declaration in support of this motion is attached hereto. CZ Petitioner’s affidavit or declaration is not attached because the court below appointed counsel in the current proceeding, and: CO) The appointment was made under the following provision of law: _ or Cla copy of the order of appointment is appended. : (Signature) AFFIDAVIT OR DECLARATION IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS L, Pant ' , 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 vate. 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 s_f ) __ s/A g_¢ 2 MLA Self-employment sO §. sO $ fai Income from real property s_O $. sO $ WV, (such as rental income) Interest and dividends sD MA s_O $ : od Gifts s 400s s 200." ¢ Alimony $ O _ § $ Oo s MA Child Support $ O 5 $ $. ) M/A Retirement (such as social $x il |. $ Al $ $. security, pensions, annuities, insurance) . Disability (such as social $ 0 s MV $_ O MA security, insurance payments) Unemployment payments $ 0 $. $ 0 $. L); Public-assistance $_ O $ sO $. A(such as welfare) i Other (specify): No { € $. 0) $ MW $ 0) _ stl, fh 10 {0 Total monthly income: $ (g | L $ , sl | L $ 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 Gress monthly pay . ’ Emplo it $ $. $. 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 Emplo nt $ $ ; $ 4, How much cash do you and your spouse have? sf) 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 yeu have Amount,your spouse has PAY LKIAA ecu, Cf ? $ 20! — $. y itu Seeuce $ : $ Saviys SAA Ao 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. © Home O Other real esjate Value M/k Value (] Motor Vehicle #1 . 0 Motor Vehicle #2 WW Year, make & model Ath Year, make & model Value 0O Value Other assets Deseription : {) | K ee Value "20,000 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 Mi s Wi ) s Mp $ s Wie $ 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”). : He We. : 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 pa