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WITHOUT PREPAYMENT OF
an me I %Q(,[?;§,g|, V, FEES AND AFFIDAVIT
O ii PO'- “ ` Det`endant(s) CASE NUMBER: C t V. /t/O. O 5 — O H 7 — SLR
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_ I, Q Q gg g· af; jg gp gs 5 [ declare that I am the (check appropriate box)
_ lj Petitioner/Plaintiff I Iovant El Other in the above-entitled proceeding; that in support of my
ll request to proceed without prepayment of fees or costs under 28 USC § 1915 , I declare that I am
I unable to pay the costs of these proceedings and that I am entitled to the relief sought in the
complaint/petition/motion.
· In support of this application, I answer the following questions under penalty of perjury:
1, Are you cturently incarcerated? E{Yes El No (If "No" goto Question 2) —-
If"YES" state the place ofyour incarceration D Q lctcc·qi_,·p -a O { ,» ee g,$%,.£] C Us +6,-
{ Are you employed at the institution? Cl Yes IE! No
Do you receive any payment from the institution? El Yes [EI No
Have the institution [tl! out the certittcate portion of this affidavit and attach a ledger sheet giant the
institzttiontsl of vour incarceration showing at least the past SIX months' transactions. Ledger
sheets are not required tor cases {tied pursuant to 28: USC §2254.
2. Are you currently employed? Cl Yes [*3/ No
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period and
give the name and address of your employer.
b. If the answer is "NO" state the date of your last employment, the amount of your take-home
salary or wages and pay period and the name and address of your last employer.
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3. In the past 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment D Yes Elf No
b. Rent payments, interest or dividends [I Yes [EE No
c. ‘ Pensions, annuities or life insurance payments Cl Yes IE' No
d. Disability or workers compensation payments [I Yes El/No
e. Gifts or inheritances ·" Elf Yes El No
f. Any other sources I] Yes IZ No
If the answer to any of the above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.
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Case 1:05-cv—OOO37—SLR Document Filed O3/15/2005 Page 2 of 2
4. D0 you have any cash or checking or savings accounts? El Yes E] No
It""Yes" state the total amount S [O gi GZ
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or
other valuable property? [I Yes ET No
If "Yes" describe the property and state its value.
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6. List th persons who are dependent on you for support, state your relationship to each person and
indicate how much you contribute to their support, OR state NONE if applicable.
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I declare under penalty of perjury that the above information is true and correct.
Dam; 3 †if " 200-5- Signature ofApplicant ';2¤L’ J 1 ; . ’ /
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