Ability to Proceed In Forma Pauperis

No question identified. : AFFIDAVIT OR DECLARATION IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS I, William Fields JR _ , 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 $_O =FSr g@ OC eG GO Self-employment gp 9 = =g 8 og Og 8 Income from real property $ Oo 8 8g 0 = =6¢ 0 GO (such as rental income) Interest and dividends gO = =8©¢ 9 §8=¢ 0 gO Gifts $0 =©6©¢_ OFC GO Alimony g$_o = = gg@_ OL GL Child Support go gg Og Og Retirement (such as social $0 $ O01 FF =—og OGL _ security, pensions, annuities, insurance) . Disability (such as social gO =r B® Otc eg OCG security, insurance payments) Unemployment payments g_° gO = dg Og OF Public-assistance $___0 $ O. = GO = §$O (such as welfare) Other (specify): =. ~~ $a Total monthly income: $ of g 8 6g 8g 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 N/A N/A N/A $0 4A -_ N/A aA $5 —N/A N/A N/A $_o 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 N/A N Fi $0 —N/A N/A N/A $_ Oo. —N/A N/A N/A $_o 4, How much cash do you and your spouse have? $___Q Below, state any money you or your spouse have in bank accounts or in any other financial institution. ; Type a account (e.g., checking or savings) Amount you have Amount your spouse has — N/A GL GFL N/A $__0 $ Q ©: © 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. 0 Home CJ Other real estate "Value __0 Value O O1 Motor Vehicle #1 () Motor Vehicle #2 Year, make & model __N/A _ Year, make & model_N/A Value __0 Value ___0 . C Other assets Description. Ss N/A Value __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 / ——_ N/A $0 $_o N/A 0 NA gs gO N/A $ Ot $$ O 7. State the persons who rely on you or your spouse for support. For minor children, list initials instead of names @.g. “IS.” instead of “John Smith”). Name Relationship Age N/A N/A ——___ N/a N/A N/A N/A N/A N/A N/A 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 — (inelude lot rented for mobile home) g 9 Are real estate taxes included? [Yes [No Is property insurance included? [] Yes [J No Utilities @lectricity, heating fuel, water, sewer, and telephone) $0 GH Home maintenance (repairs and upkeep) go gO Food go gO Clothing $0 0002 GLO Laundry and dry-cleaning $ Oo Medical and dental expenses go FFG a You Your spouse Transportation (not including motor vehicle payments) $0 . § 0 __ . Reereation, entertainment, newspapers, magazines, ete. g Oo g OF Insurance (not deducted from wages or included in mortgage payments) Homeowner's or renter’s g$_O FF og 0 Life $0 $e Health g_9 gf Motor Vehicle gO Fg Other: N/A g 9 gg 8 Taxes (not deducted from wages or included in mortgage payments) (specify): N/A g 0 FF Install