Free hawaii.indd - Hawaii

STATE OF HAWAI`I FAMILY COURT THIRD CIRCUIT

DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS

CASE NUMBER FC-D NO.

PLAINTIFF, VS. DEFENDANT,

DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS I, ____________________________________________________________, am the Plaintiff in the above-entitled case. In support of my motion to proceed without being required to prepay fees or costs or give security therefor, (knowing fully that this does not cover the request or cost for transcripts, service fees, etc.), I state that because of my poverty, I am unable to pay the costs of said proceedings or give security therefor; that I believe I am entitled to redress. I declare that the responses which I have made below are true. 1. Are you presently employed? Yes ( ) No ( ) a. If the answer is yes, state the amount of your salary per month and give the name address of your employer. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ If the answer is no, state the date of last employment and the amount of the salary per month which you received. _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

b.

Reprographics (6/08)

1

3F-P-273

DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS

STATE OF HAWAI`I FAMILY COURT THIRD CIRCUIT 2.

DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS

CASE NUMBER FC-D NO.

Have you received within the past twelve months any money from any of the following sources: a. Business, profession or form of self-employment? Yes ( ) No ( ) b. Rent payments, interest or dividends? Yes ( ) No ( ) c. Pensions, annuities or life insurance payments? Yes ( ) No ( ) d. Gifts or inheritances? Yes ( ) No ( ) e. Any other sources? Yes ( ) No ( ) In the answer to any of the above is yes, describe each source of money and state the amount received from each during the past twelve months. _________________________________________________________________________ _________________________________________________________________________

3.

Do you have any cash or do you have money in a checking or savings account? Yes ( ) No ( ) (Including any funds in prison accounts.) If the answer is yes, state the total value owned: _________________________________________________________________________ Do you own any real estate, stocks, bonds, notes, automobiles or other valuable property (excluding ordinary household furnishing and clothing)? Yes ( ) No ( ) If the answer is yes, describe the property and state its approximate value. __________________________________________________________________________

4.

Reprographics (6/08)

2

3F-P-273

DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS

STATE OF HAWAI`I FAMILY COURT THIRD CIRCUIT 5.

DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS

CASE NUMBER FC-D NO.

List the persons who are dependent upon you for support; state your relationship to those persons; and indicate how much you contribute toward their support. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

I UNDERSTAND THAT A FALSE STATEMENT OR ANSWER TO ANY QUESTIONS IN THIS DECLARATION WILL SUBJECT ME TO PENALTIES FOR PERJURY.

____________________________________ Plaintiff's Signature

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signed this _____________________ day of _____________________ , 20 ______

____________________________________ Plaintiff's Signature

APPROVED AND SO ORDERED: ____________________________________ Judge of the above-entitled Court

Reprographics (6/08)

3

3F-P-273

Reset Page

DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS