Whether the petitioner's affidavit or declaration in support of a motion for leave to proceed in forma pauperis satisfies the legal requirements

No question identified. : AFFIDAVIT OR DECLARATION , IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS I, ig fymoud J [9 / / / € 4am 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 $ / 9 6? g_ uA g$_fe2_ s MLA | Self-employment $_ 0? $ WA $_ 207 ¢_W 1A : Income from real property gL A $ MA $_ lifA sph {ie (such as rental income) , Interest and dividends gO 5 VA 3_ VLA sV/ A Gifts s_ 9° ¢ wa svl/hA sw/A Alimony g__© s_ v4 s_V/ A si / A Child Support g__o $ w/e A s_’ [fA sV LA Retirement (such as social $ O $l/ Ike $ Mv / / sVLA security, pensions, annuities, insurance) ; , Disability (such as social $ O $ W{A $ wv! | $ Vi A security, insurance payments) | Unemployment payments $ oO $ fv Lh g_iv A, { s VIA Public-assistance $ O $ Vy At $ VLA $_/V [A (such as welfare) Other (specify): $ W/ A $ VU $. Wv [A g_ WV / ft Total monthly income: $ d/o 3 $ V/ i, $ wl | $ W) /t vA wot #pplesble 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 st 4 . Employment Bayphts of Columbus Mey Have h Cony 5r/pore $ [20° ee a — $F ee ee — $F 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 Employment ee ee re $e ee ee ee $e 4. How much cash do you and your spouse have? $ 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 you have Amount your spouse has Elie ct ing $__ GE $ 7/7 ae eee OG fg fg 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. ©] Home C) Other real estate Value Ws Value IY 7 An [Motor Vehicle #1, mer wort C) Motor Vehicle #2 /, Year, make & model 22 03 Crean lng “quis Year, make & model 2 4 Value__3 00) Value C1 Other assets ; Description Vv las 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 / / ” MA s UL 4A s_ vl 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 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 ign, (include lot rented for mobile home) $ [Gee s W/A Are real estate taxes included? [Yes [No : Is property insurance included? Yes No , Utilities @lectricity, heating fuel, Ona . water, sewer, and telephone) $29 s VLA _ Home maintenance (repairs and upkeep) $. A674 s VLA. Food s_7¥OC ¢§ VSA Clothing g OO s_ LVL Laundry and dry-cleaning g_f CO sw LA Medical and dental expenses $ Oo s_ V7 ; You Your spouse Transportation (not including motor vehicle payments) § O _ s We Recreation, entertainment, newspapers, magazines, ete. $ s Mk Insurance (not deducted from wages or included in mortgage payments) | Homeowner’s or renter’s gO s V