Whether the petitioner should be granted leave to proceed in forma pauperis

No question identified. : AFFIDAVIT OR DECLARATION IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS L Samveon Qin ry 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 $_() $ NIG $ O g_ ale Self-employment gO $ Ala gs O $_ Ola _ Income from real property g$ O $_\ ow $__¢ ) $_A(Q (such as rental income) Interest and dividends $_O $_ AIGA §_ © — §$ Nile a . Gitts sD s nla s_O g Nila Alimony $ ~~) g$_ MIA $ oO $_ Al([ae ny Child Support s_O g_ Ak Ofmn'’s O g__alw Retirement (such as social ao) gs O[G_ s O | g NO security, pensions, annuities, insurance) Disability (such as social $ O gs_N{la_ ¢ O g N(e security, insurance payments) O Unemployment payments $ QO $ Nla gg 7 g__ Ma Public-assistance s_ O $ Ala § ¢ \ $_ Na (such as welfare) nw Other (specify); s_ OO s_nle s_ © | $ Na Total monthly income: $ oO g__ ala 5 O 5 Ab° 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 \ an Lenton EDO n\ ') ‘ gO ———__ Ala $e ROL unerPgT UL Yo Kalan a of aan’ \isce—A 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 A ee ee re $$ ee ee ee $$ 4. How much cash do you and your spouse have? $ awe) 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 ___ Cwecl fi (fay § FO S$ Nan ae ~~ GB LCGL 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. [Home DisPalul due b caut( Other real estate Value__2.9°); d09 Prater cl) Value TV (an of, Penns fon Funch oe verl_ Wor ard 23 uy 2 CYMotor Vehicle #1 \oNopa CMotor Vehicle #2 5 was" Vo) Avy Cu Year, make & model__D O'S Core Year, make & model see ee yan, Value Good Value C) Adon. i? ol , me LNEX pert ]o &} Other assets Virb ah re ‘ Description Alo. Value dj 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 » Doin treme Oete) s —— [ow gO a $e $e — $e $ 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 O--Cammy DaushH \ 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) $\ g TO s nl” A Are real estate taxes included? JY Yes [No Is property insurance included? $4Yes [JNo Utilities (electricity, heating fuel, water, sewer, and telephone) $_S oO gs NIA [a Home maintenance (repairs and upkeep) $ ee $s 7 O(a Food 3 AO , Ole a ON Clothing 5 SO» Ie AO aw Laundry and dry-cleaning $ g Ola , 5 O Mla Medical and dental expenses $ ° | , You Your spouse Transportation (not including motor vehicle payments) §$ doo s Nla_ Recreation, entertainment, newspapers, magaz