Free Motion for Leave to Proceed in forma pauperis - District Court of Connecticut - Connecticut

IIIII TTM Case 3;()()-cv-01116-SRU Document 44-2 Filed 03/03/2006 Page I 0* 4 I I
UNITED STATES DISTRICT COURT I'.?
DISTRICT OF CONNECTICUT I ``II I
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FINANCIAL AFFIDAVIT IN SUPPORT OF H (_ WFT ,,0,,,,I I
MOTION FOR LEAVE TO PROCEED IN FORMA PAUPEIEIIIS (‘$i )IlI*I`, IEIQII-IT·-I I I
PURSUANT TO 28 U.S.C. § 1915 I
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Plaintiff(s), I
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Defendant(s). _
I declare that:
(1) I am unable to pay such fees, costs, or give security therefor.
(2) I am entitled to commence this action against the defendant(s). I
I further state that the responses I have made to the questions below relating to my I
ability to pay the cost of prosecuting this action and other matters are true. I
MARITAL STATUS ,
Single Married Separated Divorced a I
lf separated or divorced, are you paying any support or any form of maintenance? I
Yes No I; I
Dependents: Wife Children # Others # I
and relationship I
Please provide the names and ages of your children. If a child is a minor, please {
identify the child by initials only. ;
Name Age I
Name Age j I
Name Age 5 I
Resgcenge 7 I I , 5
Street Address: ./' ¢’d'¢‘gg/ 0?”’ (€'#zvI·*·°" //543 51% ,%¢%A I
ciry;r.z/fP·r/ state: @
Zip Code: Q60?Q Telephone: “——~ I
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Rev.‘lO/3/05 2 I
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Case 3:00-cv-01116-SRU Document 44-2 Filed O3/O3/2006 Page 2 of 42 {
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Please circle the highest level of formal education you have received: i
Grammar School K 1 2 3 4 5 6 7 8 High School 91011 12 F
College @3 4 Post-Graduate 1 2 3 4 _
amptovmaur
lf at present, complete the following: ;
Name of employer: _ Q E
Address of employer: __ j
How long employed by present employer: ___ I i
Income: Monthly Weekly . i
if seIf—em lo ed state weekly wages: _
What is the nature of your employment? _____
lf unemployed at present, complete the following: · N
I have been unemployed since the day of .. C , 19 XY g
The name of my last employer: //6// 5 q; _____ E
Address: Qi m·:[<'J·( C ___
Telephone #: ——-·—~: Z I
The last salary or wages received: 75WJd _ g
lf s ouse is employed, please complete the following:
Name of employer: ____ p
l-low long employed: i {
Income: Monthly Weekly ____ ` `
What is the nature of spouse‘s employment? __ i
lf on welf re or receiving unem Io ment b neflts complete the following:
I have been on welfare or receiving unemployment benefits l
since: 5
l am receiving $ monthly weekly i
for myself and family of . ` l
lf receiving social securit , disabilit or workers' m ensation benefits complete the
following: I
I have been receiving social security, disability or workers' compensation benefits . ‘
since: . -
I am receiving $ monthly weekly . ?
FINANCIAL STATU =
Owner of real property? Yes No
If yes, description: . I
Address: ____ ‘ I
In whose name? ___
Estimated value: ____ ;
Amount owed: ___
Rev.10/3/05 3 I !
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Case 3:00-cv-01116-SRU Document 44-2 Filed 0370372006 PBQE 3 0+4 “"““`—”""—“"I
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Owed to: · I
Total: Monthly payment I I
Owed to: "7 I
Total: Monthly payment ‘
Annual income from property: I
ther r ert : I
Automobile: Make Model Year I
Registered owner(s) name(s): I
Present value of automobile: I
Owed to: :
Amount owed: I
ash or Se urities on hand:
Cash in banks and savings and loan associations: O Q _
Names and addresses of banks and associations: I
"""“*"""—":·······~—"—"·—· I
Stocks or bonds owned: !
Indicate current value and name of company and number of shares of stock or identify 3 I
bonds: _ I
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`m`”"`””`”T”"T"i—T`TT‘""‘ II
OBLI ATlONS: I I
Monthly rental on house or apartment: $ 69 _ I
Monthly mortgage payment on house: $ T
Gas bill per month: $ I I
Electric bill per month: $ I
Phone bill per month: `$
Car payments per month: $ I
Car insurance payments per month: $ ‘ I
Other types of insurance payments per month $ r I
Monthly payments to retail merchants: $ I °
Please list: $ I
Please list: $ · I
Monthly payments on any other outstanding
loans or debts: $ O
Please list: $ I
Please list: $ I
Any money owed to doctors, hospitals, lawyers I ¤
Please list: $ Z
Please list: $ Q ,
Monthly payment for maintenance or child support
under separation or dissolution agreement: $ & |
Estimated monthly expenditure on food: $ Q I =
Rev.1U/3/05 4 I
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m—__“mCase 3:00-cv-011 16-SRU Document 44·2 Fllea 6370372006 I 396 4 OI 4 “` Tg
Estimated monthly expenditure on clothing: $ §
Total amount of monthly obligations: $ J {
"_"”_—""—~·~—·— . I
Other information pertinent to financial status: (Include stocks, bonds, savings bonds, I
interests in trusts either owned orjointly owned): I
·~·—-·—
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PREVIQUS LITIGATION: I
if you have ever filed a case in this district, provide the following information for each I _
case you have filed. lf you need additional space, please continue on a separate sheet.
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Case Number Case Caption Disposition of Case ; N
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1 I 1
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3. _________*______ .......____.._,_ E I
4- —-»—-—...... —~——-——— 3
5. - .. -.. ._..o ....._......_.
Dam. {gif /5F tt700é;
Ori al Slg ure of Affiant
DECLARATION UNDER PENALTY OF PERJURY
I declare under penalty of perjury under the laws of the United States of America that
the foregoing is true and correct to the best of my knowledge and belief. g
_ l hui.-- .
Ori I Sign e of Afflant . J
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Rev.10/3/05 5
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