Whether the petitioner is entitled to proceed in forma pauperis

No question identified. : . . AFFIDAVIT OR DECLARATION oo IN SUPPORT OF MOTION FOR LEAVE TO PROCEED /JN FORMA PAUPERIS I, Darry\ ( Daniels , 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 g__9 $__ 0° ¢$ OF g¢ O Self-employment g$__O $_G gO ¢ G Income from real property $__O $0 | gO. +=§$ oO (such as rental income) Interest and dividends g¢__O g$__ 9 $_O $ oO Gifts $__O $__0 $__O $0 Alimony $__0 g$__O0 $__© $0. Child Support g_0 $ $_ Oo $F$. O Retirement (such as social $90 $ Oo g__O gO security, pensions, annuities, insurance) Disability (such as social gO g__9 g_O gO security, insurance payments) Unemployment payments $_O g__0 $_O. $_ Oo Public-assistance $__9 g$_O g_ OO £g§$_O (such as welfare) _ Other (specify); SFO $__© $_O g$_ O Total monthly income: $ 0 g$_O an @) gO 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 NIA rk s_ NA — N/A $ is _NIA [ s_ NIA 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 . $ IA — NIA NIA $s NIA 4, How much cash do you and your spouse have? $ O 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 eee eee SO EF CG © SO: © © 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. O Home CL Other real estate Value _ NA Value__O O Motor Vehicle #1 0 Motor Vehicle #2 Year, make & model NA Year, make & model N/A Value Oo Value__© , 0 Other assets : Description [ Ni \ Value SO , A 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 : ; . on © ee gO g__O OO g$ G gO —__Q gO gO 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 _ NA NANA — NIA NANA — NANA NA 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 . . (include lot rented for mobile home) gs OO s QO Are real estate taxes included? Cl Yes Jo : Is property insurance included? L Yes Ao Utilities @lectricity, heating fuel, water, sewer, and telephone) $ O $ 0 Home maintenance (repairs and upkeep) $ {e) Sg e) Food a © ee ee © Clothing g_O g O Laundry and dry-cleaning gO g¢ GO Medical and dental expenses $ 6) $ (6) You Your spouse Transportation (not including motor vehicle payments) gO gO Recreation, entertainment, newspapers, magazines, etc. g Oo gO Insurance (not deducted from wages or included in mortgage payments) Homeowner’s or renter’s gs O g O Life gO g iO. Health gO g Oo Motor Vehicle g_O =r g§ SOO Other: NIA g$_O = g¢_Q. Taxes (not deducted from wages or included in mortgage payments) (specify): _ NIA gO g O. Installment payment