Case Information
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MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS .-zlaze. 'I Pr6J~f-. f-tfZ> I s-rrt do hereby request leave to
I, proceed in forma pauperis ~d state unaer oath that I am unable to pay the costs for commencement of this _____ __ __ action, or to give security therefor, and that I believe I am entitled to redress.
I further state the foll<?w~ng: · /
I am not employed ( i~·
Imnemployedh;: ~ ~~(e/ Jkrr0-{;pWiJ fb-,// and my salary is $ __ _____ ___ per---'---~-----· I have no other sources of income except the following (include public assistance, social security disability, or any other income not included above employment and state the amount):
I have $ _____ (§ _ __,.._, ______ IN CASH.
I have the following funds in the bank:
NAME OF THE BANK TYPE OF ACCOUNT AMOUNT
- J //}I j_f ,..--- \'?\ $ .,-_ ....... /'""' $ ~ $ I own the following valuable property (include real estate, stocks, bonds, notes, automobiles, and other valuable property, but exclude ordinary household furnishings and clothing):
VALUE $ $ $ I have the following debts: