Free 3C-P-373DeclarFormaPauperis - Hawaii

IN THE CIRCUIT COURT OF THE THIRD CIRCUIT STATE OF HAWAI`I ) PLAINTIFF(S) ) ) ) ) ) VS ) ) ) ) ) DEFENDANT(S) ) ___________________________________________ )

___________ NO. ___________________

DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS

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 and address of your employer. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ b) If the answer is no, state the date of last employment and the amount of the salary per month which you received. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at the Circuit Court Administration Office at PHONE NO. 961-7440, FAX 961-7416, or TTY 961-7525 at least ten (10) working days prior to your hearing or appointment date.
Reprographics (03/07)

DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS 3C-P-373

2. Have you received within the past twelve months any money from any of the following sources? a) Business, professional or form of self-employment? Yes No b) Rent payment, interest or dividends? Yes No c) Pension, annuities or life insurance payment? Yes No d) Gifts or inheritances? Yes No e) Any other sources? Yes 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. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 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: ____________________________________________________________________________________ 4. 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: ____________________________________________________________________________________ 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 ____________________________________________________________________________________

Reprographics (03/07)

DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS 3C-P-373

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

Reprographics (03/07)

DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS 3C-P-373

CLEAR