Whether the petitioner's inability to pay the costs of this case or provide security therefor, as stated in the affidavit or declaration, entitles the petitioner to proceed in forma pauperis

No question identified. : : AFFIDAVIT OR DECLARATION IN SUPPORT OF MOTION FOR LEAVE TO PROCEED JN FORMA PAUPERIS I, Wi2A , am the petitioner in the above-entitled case. In support of my motion to proceed in fama 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_ «WAL 5 O_ g Viz Self-employment $ $ $ $ Income from real property $ $ $ $_ (such as rental income) Interest and dividends $ $ $ $_ Gifts $ $ $ S$ Alimony $ $ $ $_ Child Support $ $ $ $——___— Retirement (such as social $ $ $ $e security, pensions, annuities, insurance) Disability (such as social $ $ $ $e security, insurance payments) Unemployment payments $ $ $ $ Public-assistance $ $ $ $_ (such as welfare) Other (specify): $ $ $ $_ Total monthly income: $ $ $ . $e ; 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 oe ——pr— ———a — $o EE — ee $o 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 ft Employment a 0 an es —— _ $e — ee a $o 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 $e G wt $n gg _ $__ _ ~ $$ 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. 1] Home C Other real estate Value Value CI Motor Vehicle #1 Cl Motor Vehicle #2 Year, make & model Year, make & model Value Value C Other assets Description Value , You Your spouse Transportation (not including motor vehicle payments) 5 O sO Recreation, entertainment, newspapers, magazines, ete. $ $ Insurance (not deducted from wages or included in mortgage payments) Homeowner’s or renter’s $ SS Life $ $ | Health $ ~ Motor Vehicle $. $. Other; $ $ Taxes (not deducted from wages or included in mortgage paymen' (specify); — $ $ Installment payments Motor Vehicle $ $ Credit card(s) $ $ Department store(s) $ $ Other: $ $e Alimony, maintenance, and support paid to others $ $s Regular expenses for operation of business, profession, or farm (attach detailed statement) $ $e Other (specify); — $ S$ Total monthly expenses: a ST A A I ET ES 6. State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or Amount owed to you Amount owed to your spouse your spouse money _ =a $ | pict is $_ — —— aS ~ — $$ | 7. State th: ns who rely on you or your spouse for support. For minor children, list initials instea (e.g. “J.S.” instead of “John Smith”). Nara 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 2) © | (include lot rented for mobile home) § $. | Are real estate taxes included? [1 Yes CINo | Is property insurance included? [1 Yes (I No | Utilities (electricity, heating fuel, ! s | water, sewer, and telephone) $ $ Home maintenance (repairs and upkeep) $ $. Food $ $ Clothing $ $j Laundry and dry-cleaning $ $ Medical and dental expenses $. $