Free untitled - California

United States Court of Appeals
FOR THE DISTRICT OF COLUMBIA CIRCUIT

USCA No.

MOTION FOR WAIVER OF FEES

I,

, declare that because of my

poverty I am unable to prepay the costs of retrieval and photocopying the requested documents in the above case. My affidavit is attached.

I believe I am entitled to these documents because: (Provide a statement of the reasons you wish to present to the Court. You may continue on the other side of this sheet if necessary.)

Signature Name of Requester (Print) Address

Submit original to: Clerk U.S. Court of Appeals for the D.C. Circuit U.S. Courthouse, Room 5523 Washington, D.C. 20001

USCA Form 53b (Rev 7/2007)

United States Court of Appeals
FOR THE DISTRICT OF COLUMBIA CIRCUIT

AFFIDAVIT IN SUPPORT OF MOTION TO WAIVE FEES
I swear (affirm) that the responses which I make below to the questions concerning my ability to pay the costs as stated in the motion are true. 1. Are you presently employed? a. G Yes G No

If the answer is "yes", state the amount of your salary or wages per month and give the name and address of your employer. (List both gross and net salary.)

b.

If the answer is "no", state the date of your last employment and the amount of the salary and wages per month which you received.

2.

Have your received within the past twelve months any income or property from any of the following sources? a. b. c. d. e. Business, profession or other form of self-employment? Rent payments, interest, or dividends? Pensions, annuities or life insurance policies? Gifts or inheritances? Any other sources? G Yes G Yes G Yes G Yes G Yes G No G No G No G No G No

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.

USCA Form 53b (April 2000)

3.

Do you own any cash or checking or savings accounts (including joint accounts)? G Yes G No a. If the answer is "yes", state the total value of the items owned. $

4.

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

5.

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

I declare under penalty of perjury that the forgoing is true and correct.

Signature of Applicant Name of Requester (Print) Address

Executed on (date)

USCA Form 53b (April 2000)