Free Form 4 - Hawaii

Public Utilities Commission STATE OF HAWAI#I

) ) Plaintiff, ) ) v. ) ) ) ) Defendant. ) _________________________) AFFIDAVIT IN SUPPORT OF MOTION FOR LEAVE TO PROCEED ON APPEAL IN FORMA PAUPERIS STATE OF HAWAI#I COUNTY OF Maui ) ) SS. )

I, , being first duly sworn, depose and say that I am the Defendant in the above-entitled case; that in support of my motion to proceed on appeal without being required to prepay fees, costs or give security therefor; I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am entitled to redress; and that the issues which I desire to present on appeal are the following:

I further state that the responses which I have made to the questions and instructions below relating to my ability to pay the cost of prosecuting the appeal are true. 1. ARE YOU PRESENTLY EMPLOYED? a. If the answer is yes, state the amount of your salary or wages per month and give the name and address of your employer.

IA-P-004 (12-05)

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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 YOU RECEIVED WITHIN THE PAST TWELVE MONTHS ANY INCOME FROM A BUSINESS, PROFESSION OR OTHER FORM OF SELFEMPLOYMENT, OR IN THE FORM OF RENT PAYMENTS, INTEREST, DIVIDENDS, OR OTHER SOURCE? a. If the answer is yes, describe each source of income, and state the amount received from each during the past twelve months.

3.

DO YOU OWN ANY CASH OR CHECKING OR SAVINGS ACCOUNT? 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)? a. If the answer is yes, describe the property and state its approximate value.

5.

LIST THE PERSONS WHO ARE DEPENDENT UPON YOU FOR SUPPORT AND STATE YOUR RELATIONSHIP TO THOSE PERSONS.

IA-P-004 (12-05)

I understand that a false statement or answer to any questions in this affidavit will subject me to penalties for perjury.

________________________________ Subscribed and sworn to before me this ____ day of ______, 20____. _____________________________ Notary Public, State of Hawai#i My commission expires: _________ [ ] [ ] Application granted. Application denied for the following reason: [ ] Appeal is not taken in good faith. [ ] Applicant does not meet financial qualifications.

___________________________________ Judge of the above-entitled court

IA-P-004 (12-05)