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No question identified. : AFFIDAVIT OR DECLARATION IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS -S.IR ALBERR .L‘ JOHNSDON am the petitioner in the above-entitled ease. 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 the past 12 monthsAmount expected next month You Spouse n/aYou Spouse n/a S IQ.00 10.00 Employment Self-employment Income from real property (such as rental income) Interest and dividends$. $. $. $ n/a n/a n/a n/a $. $. $. $. $. $. $. / $. $___ $. $. Gifts $__ 1 $. $. $. Alimony $. $. $. $. Child Support $. $. $. $. Retirement (such as social security, pensions, annuities, insurance)$. $. $. $. Disability (such as social security, insurance payments) Unemployment payments$. $. $. $. $. $. $. $. $. Public-assistance (such as welfare)$. $. $. Other (specify): $. $. $. $.\ 10.0.0 Total monthly income: $ 10.00 $. $. $. -2 o^4 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 EmploymentP.0.BOX 4000 @)2022 thru pres ent $ FMC ROCHESTERGross monthly pay 108.00 BOP $. $. ROCHESTER MN. 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.) Dates of EmploymentGross monthly pay Address Employer n/a $. $. $. 4. How much cash do you and your spouse have? $10.00 _ Below, state any money you or your spouse have in bank accounts or in any othei^ financial institution. Type of account (e.g., checking or savings) Amount you have Amount your spouse hasn/a $ $. $. $. $. $. 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. EH Other real estate Value $?million□ Home Va.1ne $ 10QK □ Motor Vehicle #2 Year, make & model Value _□ Motor Vehicle #1 Year, make & model Value _n/a n/a □ Other assets Description _ Value _n/a jgj[ 6. State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or your spouse money BUR. OF PRISONS SISAmount owed to you Amount owed to your spouse $ $. a total of GILLION Ecktrillion $ LT. GRAINIER, OFF. $. $. 7. State the persons who rely on you or your spouse for support. For minor children, list initials instead of names (e.g. “J.S.” instead of “John Smith ”). Relationship Name Age NONE 8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, or annually to show the monthly rate. Your spouse You Rent or home-mortgage payment (include lot rented for mobile home) Are real estate taxes included? M Yes □ No Is property insurance included? 0 Yes □ No$ n/a $ unknoewn Utilities (electricity, heating fuel, water, sewer, and telephone) n/a $. $. n/a $. $. Home maintenance (repairs and upkeep) $. $. Food $. $_ Clothing $. $. Laundry and dry-cleaning $. $. Medical and dental expenses You Your spouse Transportation (not including motor vehicle payments) $. $. n /a n/a Recreation, entertainment, newspapers, magazines, etc. $. $. Insurance (not deducted from wages or included in mortgage payments) n/a n/jL$. $. Homeowner ’s or renter ’s $. $. Life $. $. Health $. $. Motor Vehicle $. $. Other: Taxes (not deducted from wages or included in mortgage payments) n/a n/a n/a$. $. (specify): Installment payments n/a n/a $. $. Motor Vehicle \ $