Free Request to Proceed in Forma Pauperis (Criminal/Family Court Criminal) - Hawaii

IN THE

OF THE FIFTH CIRCUIT STATE OF HAWAI`I ) ) ) ) ) ) ) ) ) ) ) ) Case no. ______________________ DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS

STATE OF HAWAI`I,

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 an 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 therefore; 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 and address of your employer.

b) If the answer is no, state the date of the last employment and the amount of the salary per month which received.

In accordance with the Americans with Disabilities Act and other applicable state federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at the Court Administration Office at PHONE NO. 482-2347, FAX 482-2309, OR TTY 482-2533 at least ten(10) working days prior to your hearing or appointment date.
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2.

Have your received within the past twelve months any money from any of the following sources? a) Business, professional or form of self-employment? [ ] Yes [ ] Yes c) d) e) [ ] Yes [ ] [ ] [ ] No [ ] No [ ] No b) Rent payment, interest or dividends? Pension, annuities or life insurance payment? Gifts or inheritances? Yes [ ] No Yes [ ] No Any other sources?

If 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 account) If the answer is yes, state the total value owned:

4.

Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property(excluding ordinary household furnishings and clothing) ? [ ] Yes [ ] No If the answer is yes, describe the property and state its approximate value:

5.

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.

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I UNDERSTAND THAT A FALSE STATEMENT OR ANSWER TO ANY QUESTION 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
CLEAR FORM

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