Address ’~75‘ **5 3 $ 2 Qhmp CN ~.. F1ECErvg¤ COP
1 %ll?/, lSltate, Zip bg, mfg c,,_ L Iq L eg 51;. 1 ')_ Y
2 eep onenum er ,_‘<6OglO7*(9Ic5L__' UCI 062005
eo) q<6<6— ge et LQ ¤· u CLERK US mm .
3 BYE orsrnrcr or A§_—;§,?AURT
4
IN THE UNITED STATES DISTRICT COURT
5 FOR TI-IE DISTRICT OF ARIZONA
6 Gm more ‘€ Qwcge ¤ pla
7
Plaintiff]
8 Cv —¤a·o1<-11°r—P1+ic—Sr-xT
9 VS` -— MOTION TO PROCEED
l¥Q%e+\— \~F&%O"* ““ ‘ °‘°‘ ‘°°$¤ Q 'U IN roman PAUPERIS and
10 I \| , me x3 eb QQ E°\`Y`i <> rv SUPPORTING INFORMATION
Defendant.
11
12
I3 Ii QE; ggg g 8 ; A QQ declare that I am the Plaintiff in this action;
14 that I hereby request to proceed without being required to prepay fees, costs or give security
I5 therefore. I state that, because of my poverty, I am Lmable to pay the fees of said proceeding;
16 that I believe I am entitled to relief.
17 In further support of this application, I answer the following questions:
18 I. Are you presently employed? Yes @
19 a. If the answer is “yes", state the amount of your salary or wages per month and
20 give the name and address of your employer.
21
22
23 b. If the answer is "no", state the date of last employment and the amount of the
I 24 salary and wages per month which you received.
25 .../
26 \ I 93 I 0 B O
O \ \ \
27 4
23
Arrncnmewr 6
Case 2:03-cv-01419-JAT Document 52 Filed 10/06/2005 Page 1 of 2
5QQ Q:~\’¤·.¥v.¤& IVD \c|CtL.|
_: `n ¢ Ck wk C
‘ l 2. .- Is yotu· spouse employed? X WO { _. No
I 3. Have you received within the past twelve months any money from any ofthe following
2 sources?
3 a. Business or other fonn of self employment Yes @
4 b. Rent payments, interest or d1v1dends Yes ®
5 c. Pensions, annuities or life insurance payments Yes
6 d. Giits or inheritances Yes i.. • I
7 e. Any other sources ( .
8 If the answer to any of the above is "yes", describe each source of money and state the
9 amount received from each during the past twelve months.
Imcome "W%——,¢¢°% QQOGO
10 vtdttf : 3 { qo© ‘
H 4. Do you own any cash, or do you have money in checking or savings accounts?
12 If the answer is "yes", what is the amount of money you own in cash
13 checking account , savings account
14 5. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable
property (excluding household furnishing and clothing Yes · °*’
I5 ». . . . [’><¤li€\¤th* TV
16 If the answer 1S "yes", descr1be and give estimated value of each.
17 6. List the persons who are dependent upon you for support, state your relationship to
18 those persons, and indicate how much you contribute towards their support.
19 I declare under penalty of perjury that the forgoing is true and correct.
20 DATED this pg day or ©c»l¤\O~¤r ,2005.
:TYf`M-J,-a-F #
21 I um ""*~·-.____·`r—N-l {//./I
Dgl\'>
\>€"l\——€»x Qantas Q#f#°f¤f¤ § [gra?/gh
23 our ngme type or pri
K ‘ A
24 mg O<-g lrl-·»& Mr tl M ‘°‘ ME
564 2. YSQK Q.
25 (©w€. c>~(C AAWQ-M SQF , ess 9 é S/L
07 · /
26 Wl Vi e ep one um er
27 é0¤°~ VY? 'écé /
28
Case 2:03—cv—01419—JAT Document 52 Filed 10/06/2005 Page 2 of 2
Case 2:03-cv-01419-JAT
Document 52
Filed 10/06/2005
Page 1 of 2
Case 2:03-cv-01419-JAT
Document 52
Filed 10/06/2005
Page 2 of 2
United States Free Forms
Canada Free Forms
United Kingdom Free Forms
Australia Free Forms