Whether the petitioner is entitled to proceed in forma pauperis

No question identified. : i ; | oy CO) . . AFFIDAVIT OR DECLARATION IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS ; I, JAMES DAVID WREN, 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 T believe I am entitled toredress. ~ 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 oy otherwise. Income source Average monthly amount Amount expected During the past 12 months next month : . — You Spouse You Spouse Employment $0 = $ ; Selfemployment =~ §_0 ¢ ~§ | Income from real property $0 = Sg oo (such as rental income) . . Interest and dividends g _ oO $ $ : Gifts $s 0s g S$ ; . ; Alimony $0 $ _§ $ : Child Support $0 ¢ $ _ ~ S$ Retirement (such as social $0 ¢ $ — S$ security, pensions, annuities, insurance) ' Disability (such as social $0 S$ a oe F security, insurance I payments) . ; ‘ Unemployment payments $___ 0 ¢ — Hg : Public assistance $0 g : S$ $e i (such as welfare) . ; oo : Other (specify): $0 =8g $ $ Do Total monthly $0 g $ $ . . income: . 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 NA Sn 3. List your spouse's employment history for the past two years, most recent employer first. (Gross nionthly pay is before taxes or other deductions.) ‘ Employer Address Dates of . Gross monthly pay ; Employment ; ee ae ee [a . : 4, How much cash ‘do you and your spouse have? $0 . . ae 5. Below, state-any money you or your spouse have in bank accounts or in any other financial institution. Financial institution Type of account Amount you have Amount your spouse has N/A $: $ A ao Be a 6. List the assets, and their values, which you own, or your spouse owns. Do not list clothing and ordinary household furnishings. : , Home , @ Other veal estate : Value id) : Value 0 ’ © Motor Vehicle #1 © Motor Vehicle #2 : Year, make & model 0 Year, make & model 0 ‘ Value Value . i ' o Other assets ; : I Description MA { Value : L 7. 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 your spouse money spouse ee RB S$ 7. State the persons who rely on you or your spouse for suppoxt. : Nam , Relationship Age e SW. DAUGHTER 11 JW. . SON 12 gw ti(<té‘« SN 8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by 7 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 (include. : lot rented for mobile home) gS $ Ave real estate taxes included? Yes 3 No ; Is property insurance included? @Yes a N : Utilities (electricity, heating fuel, : : water, sewer, and telephone) ; $0 $ Home maintenance (repairs and upkeep) Gg 0 ¢$ Food $C GS Clothing : gC $ : _ Laundry and dry-cleaning g$_ CC $ Medical and dental expenses — $e O $ : | You ; Your spouse ‘Transportation (not including motor vehicle payments) $= =O gg Recreation, entertainment, newspapers, magazines, etc. $s 0 sg Insurance (not deducted from wages or included in mortgage payments) “Homeowner's or renter’s $C Life $0 § : Health $0 F§ Moto Vehicle $i OG Other: $0 $ ; : Taxes (not. deducted from wages or included.in mortgage payments) Le me ee (specify): Sg Installment payments “Motor Vehicle $F Credit card(s) . $s 0 P98 Department store(s) $C Fg _ , ; Other $s O Fg Oe | ; Alimony. maintenance, and support paid to others a Regular expenses for operation of business, profession, :