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					Riches v. Karr et al

Doc. 1

Case 2:07-cv-02103-RTD-JRM

Document 1

Filed 09/20/2007

Page 1 of 2

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Districtor Al/<Ao*5A5**'*n**
APPLICATIONTO PROCEED WITHOUT PREPAYMENTOF FEESAND AI'$IDAVIT

Rr *$.^u Lee.. "ilPTo r,r
Plaintiff V.

ll6lln' l"1n.K Karr *ol, FtL.
Defendant

.ASENUMBER: 0]-

l-t Ol

dcclare that I am the (cheokappropriate box) ffpctitioner/plaintiff/movant tr other in thc above-entitlcd proceeding; in supporlofmy request proceetl that withoutprepayment to offees or costs under28 USC $1915I dcclare I amunable paythe costs that to oftheseproceedings thatIarn efltitledto therelief and soughtin the complaint/petitioni motion., In support ofthis application, answer following questions I the undcrpenaltyof perjury: i. Are you currentlyincarcoratcd? d Yes If "Yes," statethe placeof your incarcemtion Are you employed the institution at I \/r7 tr No (If ,.No," go to parl ?)

Do you receiveanypalrnentfrom the institution? ,l?{ a, prunth

2.

Attacha ledgctsheet from the inslitution(s) ofyour incaroeration showingat leastthe pa$tsix months' trunsactions. l4 g*rr.,kt,11 Are you currentlyemploycd? dYe" DNo a. If theanswer "Yes," state amount is the ofy_our take-home salary wagcs payperiodandgive thename or arui andaddress ofyour employer. ,\?\ 4 _r,*ft^ prrtoo Job b. If theanswer "No," state dateof your lastemplolment, amount yourtake-home is tbe the of salary wages or andpayperiodandthenameantd ofyour lastcrnployer. address

3.

.hrthe past 12 twelvemonthshaveyou rcceivedanymoneyfrom anyofthe following sources? a. b. c. d. e. f. Business, professionor otherself-employmont interest dividends Rcntpayments, or Pensions, or pal.rnents annuities life insurancc Ilisability or workerscompensation payments Gifts or inhoritances Any other souroes E tr E D I tr yes Yes Yes yes Yes Ycs C*o .Att-lo ,{no H Uo d. trto d lto

Ifthe answerto anyofthe above "Yes," desoribc, the following page,eachsource moneyand statethe is on of amountreceivcdandwh8tyou expcctyou will continueto receive.

Dockets.Justia.com

Case 2:07-cv-02103-RTD-JRM
AO 240 Rcvenc (Rcv. I

Document 1

Filed 09/20/2007

Page 2 of 2

4,

Do you haveany cashor checking savings accounts? or If "Yes," statethe total amount.

! Yes

r1rqo

5.

Ilo yori own aly real estate, stocks, bonds, otherfinancialinskuments, gecuritics, or autofirobiles irnyother thine of value? E Yes EI No If "Yes," describc propertymd stflteits value. thc

6.

List thc persons who aredepcndent you for support, on statoyour rclationship eachpcrsonand indicate to how muchyou contribute their support. to

A)
I declare underpenaltyof pe{ury that the abovcinformationis true andcorrect.

------lT"r"-

q l r oq - 1 I

CERTIFICATE
(lnca-rceroted Epplicf, ody) Ets (To bo conplete.{i thEinstitutionofincarcEnrtion) by

I certifythat the applicant named herpinhasthe sum oI $ d J, 5 5

institutioni lCJ.

'l lr,t/, l,'aq, S bu,- q

on account his,ther to creditat (nameof

. I fluther oortifu theapptioanr the rhar has
and the

following securities his,4rcr uedit: to I iiirther certifythat during thepastsix monthsthe applicant's average balanoe $ was

applicant's average monthly deposit S-l 3 0' 0 A *^r

STGNATURE ATITHORIZEI] OF OFFICER


				
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