Free Indigent Petition-to-Sue Form - North Carolina

State of North Carolina North Carolina Industrial Commission

PETITION TO SUE AS AN INDIGENT PERSON
v.
Plaintiff's Name Defendant's Name

IC File # TA-

AFFIDAVIT As the individual plaintiff in the above-entitled action, I affirm that I am financially unable to advance the required costs for the prosecution of this action before the North Carolina Industrial Commission. Therefore, I now petition the Industrial Commission for an order allowing me to bring suit in this action as an indigent.
Check one or more of the boxes below as applicable

I am presently a recipient of Food Stamps Aid to Families With Dependent Children (AFDC). Supplemental Security Income (SSI) I am a prison inmate. A Department of Corrections report is attached showing deposits, withdrawals, and balances in my prison trust account during the last six months. Although I am not a recipient of food stamps, AFDC, or SSI, I am financially unable to advance the costs of filing this action or appeal. (An affidavit listing my income and expenses is attached)

Sworn and subscribed to before me

Signature

Date

Name of Applicant (Please Print)

Title of Person Authorized to Administer Oaths

Signature of Applicant

SEAL Date Commission Expires Date

ORDER Based upon the Affidavit appearing above, it is ORDERED that: The applicant is authorized to bring suit as an indigent The petition is denied. Commissioner Signature Date Executive Secretary Deputy Commissioner

Mail Affidavit to:

North Carolina Industrial Commission Docket Section 4336 Mail Service Center Raleigh, NC 27699-4336