Free Affidavit - District Court of Arizona - Arizona

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cg`? If {OM 2 - AFFIDAVIT OR DECLARATION C
. IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA. PAUPERIS · ‘
I. Calvin `Ffenk M0ffiS , am the petitioner in the above-entitled case. In
supportof my motion to proceed without being required to prepay fees, costs or give security I
. therefor, I state that because of my poverty l am unable to pay the costs of this case or to give
security therefor; and I believe I am entitled to redress. ` .
_ Ifurther swear that the responses I have made to the questions and instructions below
relating to my ability to pay the cost of proceeding in this Court are true. ‘ I
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1. me you presently employed? Yes ;__ No _’f_ ___ Ftecetvtzo ___ COPY
. a. If the a.nswer is yes, state the amount of your salary or wages · r month and give the . ‘
‘ · name and address of your employer. MAR 1 2 ZUU8 · I
` ‘ · ' CLERK U s tzsasrtattzt count _
DletHlG1' OF Al-ll?ONA
BY _ . S DEPUTY
. - b. If the answer is no, state the date of your last employment and e amount o s - or `
· 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 self-employment, or in the form of rent payments, interest; dividends, or other
sources? Yes _ No>_{__c · · -
_ . IF a. If the answer is yes, describe each source of income and state the amount received .
from each during the past twelve months. I
3, Do you own any cash or have a checking or savings account? Yes __ No L '
a. If the answer is yes, stat_ the total value of the items owned. I .
.·... c c ew 4t I Do you own. any-- rea.l·estatet,··tstocks. bonds, notes, automobilesi or other valuable I
_ pmperrytexcluding ordinary household furnishings and clothing) Yes ___ Iflo A _ p _ y _ ,
- -- a. Ifthe answer is yes, describe the properry and state its approximate value. -
5. I `List thepersons who are dependent upon you for support and state your relationship Ito
those persons. ‘
.- I I I declare under penalty of perjury that the foregoing is n·ue and corrgct. _.
_ Executed on: 3[1[Q§ , ___. (_;,‘<;,ég,,Z.. 6*--—.. `;, . _
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A- I (Signature) I
I I Case 2:04-cr—O1088-JAT Document 148 Filed O3/t 2/2008 Pagel of1

Case 2:04-cr-01088-JAT

Document 148

Filed 03/12/2008

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