WPCr  _Y'AwAvqi9U6ޒQ}16̽".C] *]**k˻#3\!5 ; kا1|$Wvl D'8ORiy!C ,ktp3.6EIUS"d6!he؏ 2|~f|56sd`!\A٦L_ATtW.$|\{7^Foj oU>u_d: f}:=X^r 52oFVbc/Q⺁kcYn[`w|2qjәKe|.ѧA\\}955AJs"}cSOۙ zJԓMۨ7p4譎GtҥQz( +9ouZ8N'\ ^= ZX-}2ſLO3F/(l{ uNjLTݾ::rf#UN] % ^ 0: w 4   N m" " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " U@9 9 9 9 fy a{ f a f a f a f a f a f a f a f) a+ f? aA A A A A A A A A A A A A A A A A A A A A A A A BU HP LaserJet 6MP,,,,,,,,0(9 Z6Times New Roman RegularX18Z ($USUS.,}o7am Files\Wor3|xU(9 Z(Times New Roman TABLE ATABLE BTABLE CTABLE CTABLE DTABLE DTABLE ETABLE FTABLE GTABLE H d !USUS.,  _  XUnitedStatesDistrictCourt#X$XL#  forthe ` 6X$XXX$<__________________>ԀDISTRICTOF<__________________>B#X$XX6X$# L   .<X<(#(#., $      `  Plaintiff(s)      ` v.    , \     `  Defendant(s) 4    ) $  )    )   )   )   ) p  ) \  ) H  ) 4  )  p  CaseNo.<Number> p  .<X<. @ AFFIDAVITACCOMPANYINGMOTION H @  FORPERMISSIONTOAPPEALINFORMAPAUPERIS  4 *:e;eddd Xdd Xdd X(#(#,dd ,dd +      AffidavitinSupportofMotion   p ̀Iswearoraffirmunderpenaltyofperjury H  that,becauseofmypoverty,Icannotprepay 4! thedocketfeesofmyappealorpostabondfor  " them.IbelieveIamentitledtoredress.Iswear  # oraffirmunderpenaltyofperjuryunder $ UnitedStateslawsthatmyanswersonthis % formaretrueandcorrect.(28U.S.C.1746; & 18U.S.C.1621.) l' ̀Signed:_____________________________  0!*  Instructions   p+ ̀Completeallquestionsinthisapplicationand H- thensignit.Donotleaveanyblanks:ifthe 4. answertoaquestionis"0,""none,"or"not  / applicable(N/A),"writethatresponse.Ifyou  0 needmorespacetoansweraquestionorto 1 explainyouranswer,attachaseparatesheetof 2 paperidentifiedwithyourname,yourcase's 3 docketnumber,andthequestionnumber. l4 ̀Date:_____________________________(0!7  (Myissuesonappealare: $$t9 1.0  Forbothyouandyourspouseestimatetheaverageamountofmoneyreceivedfromeach )$? ofthefollowingsourcesduringthepast12months.Adjustanyamountthatwasreceived *%@ weekly,biweekly,quarterly,semiannually,orannuallytoshowthemonthlyrate.Use +&A grossamounts,thatis,amountsbeforeanydeductionsfortaxesorotherwise.p,'B(#(#  \-(C _*<e=deddd dd :e;(#(#,N dd ,dd ,edd ,dd ,edd +  ( (Incomesource <2#d <Averagemonthly d amountduringthepast P 12months .$< .Amountexpectednext d month %P %  X You  l Spouse  l You  l  Spouse  l  Employment   <  $   <  $   <  $   < $   < Self-employment  l  $  l  $  l  $  l  $  l  QIncomefromrealproperty(suchas  < rentalincome)   (  $   < $   < $   < $  < Q Interestanddividends  X  $  X  $  X  $  X  $  X  Gifts  (  $  ( ! $  ( " $  ( # $  ( $ Alimony  X % $  X & $  X ' $  X ( $  X ) Childsupport  (* $  (+ $  (, $  (- $  (. Retirement(suchassocialsecurity, X/ pensions,annuities,insurance)  D0 $  X1 $  X2 $  X3 $  X4 Disability(suchassocialsecurity, 5 insurancepayments)  6 $  7 $  8 $  9 $  : Unemploymentpayments  0; $  0< $  0= $  0> $  0? Public-assistance(suchaswelfare)  @ $  A $  B $  C $  D Other(specify): 0E   lF $  0G $  0H $  0I $  0J ЀTotalmonthlyincome: K  ' L '$ 'M '$ 'N '$ 'O '$"P  "&  2.0  Listyouremploymenthistoryforthepasttwoyears,mostrecentemployerfirst.(Gross |#R monthlypayisbeforetaxesorotherdeductions.)'|#h$S(#(# *>e?ddN dd N dd edd edd edd e<e=(#(#,rdd , dd ,dd ,dd +  $@&!U@&! $Employer '&!V 'Address '&!W 'Datesofemployment '&!X 'Gross &!Y monthlypay '"Z   )`$[   )`$\   )`$] $  )`$^   *%_   *%`   *%a $  *%b   ,`'c   ,`'d   ,`'e $ ,`'f   ,-|(f Ї&  3.0  Listyourspouse'semploymenthistoryforthepasttwoyears,mostrecentemployerfirst.  (Grossmonthlypayisbeforetaxesorotherdeductions.)'(#(# *@eAddrdd r dd dd dd >e?(#(#,rdd , dd ,dd ,dd +  $tt $Employer '( 'Address '( 'Datesofemployment '( 'Gross ( monthlypay    D     D     D   $  D                $      D    D    D  $ D   4.0  Howmuchcashdoyouandyourspousehave?$________8 (#(# &  0  Below,stateanymoneyyouoryourspousehaveinbankaccountsorinanyother `  financialinstitution.'`!L(#(# *BeCddrdd r dd dd dd @eA(#(#,` dd ,Sdd ,dd ,dd +  $$$ $FinancialInstitution '8 'TypeofAccount '8 'Amountyouhave '8 'Amountyour 8 spousehas $t    !   " $  # $  $   $t%   $t& $  $t' $  $t(   )   * $  + $ ,   Ifyouareaprisoner,youmustattachastatementcertifiedbytheappropriateinstitutional - officershowingallreceipts,expenditures,andbalancesduringthelastsixmonthsinyour . institutionalaccounts.Ifyouhavemultipleaccounts,perhapsbecauseyouhavebeenin |/ multipleinstitutions,attachonecertifiedstatementofeachaccount.  d0 5.0  Listtheassets,andtheirvalues,whichyouownoryourspouseowns.Donotlistclothing $"t3 andordinaryhouseholdfurnishings.#`4(#(# *DeEdd` dd ` Sdd Sdd dd BeC(#(#, dd , dd , dd +  $$8 6$8  $ Home BBB 'L% 7 ' Otherrealestate 8838 'L% 8 ' Motorvehicle#1 ""J" L% 9 (Value)$  &": (Value)$  &"; (Value)$  &"<  * L(#= * &L(#> &Makeandyear:  L(#?   h)$?   h)$? Model:  )%@   *8&@   *8&@ Registration#: L+&A  _  h,'A *FeGdd dd dd dd DeE(#(#, dd , dd , dd +  $ $ Motorvehicle#2 BBB 'd ' Otherassets 'd ' Otherassets d (Value)$   (Value)$   (Value)$   Makeandyear:  d   d   d  Model:               Registration#:   d     d   d  6.0  Stateeveryperson,business,ororganizationowingyouoryourspousemoney,andthe X  amountowed.D (#(# *HeIdd dd dd dd FeG(#(#, dd , dd ,` dd +  $   $Personowingyouoryourspouse 0  money 'l  'Amountowedtoyou '0  'Amountowedtoyour 0  spouse l     $   $     l $  l $  l     $  ! $  "   l# $  l$ $ l%  7.0  Statethepersonswhorelyonyouoryourspouseforsupport.`'(#(# *JeKdd dd   dd  ` dd ` HeI(#(#,dd , dd ,dd +  $8)8 $Name[or,ifaminor(i.e.,underage),initialsonly] 'L* 'Relationship 'L+ 'Age L,   -   .   /   L 0   L 1   L 2   !3   !4  !5  8.0  Estimatetheaveragemonthlyexpensesofyouandyourfamily.Showseparatelythe $ 7 amountspaidbyyourspouse.Adjustanypaymentsthataremadeweekly,biweekly, % 8 quarterly,semiannually,orannuallytoshowthemonthlyrate.&!9(#(# *LeMdddd  dd dd JeK(#(#, dd ,udd ,dd ,Fdd +  (p(#;p(# ( * ($$< *You '($$= 'YourSpouse "($$> "Rentorhome-mortgagepayment(includinglotrentedfor T*%? mobilehome) @+&@  l Arerealestatetaxesincluded? $ []Yes[]No ,,|'A Ѐ l Ispropertyinsuranceincluded? $ []Yes[]No  -h(B $  T*%C $  T*%D _Utilities(electricity,heatingfuel,water,sewer,andtelephone)  d  $  d $  d Homemaintenance(repairsandupkeep)   $   $   Food  d $  d $  d  Clothing     $     $     Laundryanddry-cleaning   d  $   d $   d Medicalanddentalexpenses    $    $    Transportation(notincludingmotorvehiclepayments)  d  $  d  $  d  Recreation,entertainment,newspapers,magazines,etc.    $    $    Insurance(notdeductedfromwagesorincludedinmortgagepayments) 'd  '    Homeowner'sorrenter's: 'e  '$ 'e e '$ ' e ' 'd 'Life: $d $$  d  $  d!  '" 'Health: $# $$  $ $  %  'd& 'Motorvehicle: $d' $$  d( $  d)  '* 'Other: $+ $$  , $  - Taxes(notdeductedfromwagesorincludedinmortgage d. payments)(specify):  P/ $  d0 $  d1 Installmentpayments '2 '  P3 MotorVehicle: 'eP4 '$ 'eP5e '$ 'P6e ' '7 'Creditcard(name): $8 $$  9 $  :  '!P; 'Departmentstore(name): $!P< $$  !P= $  !P>  '"? 'Other: $"@ $$  "A $  "B Alimony,maintenance,andsupportpaidtoothers  $PC $  $PD $  $PE Regularexpensesforoperationofbusiness,profession,or % F farm(attachdetailedstatement)  l&!G $  % H $  % I Other(specify):  '<#J $  '<#K $  '<#L   l Totalmonthlyexpenses: ! l)$M !$ 'l)$N '$"l)$O  "  t+&P &   9.0  Doyouexpectanymajorchangestoyourmonthlyincomeorexpensesorinyourassets  orliabilitiesduringthenext12months?(#(# 0  []Yes0 (#(#[]No0 (# (#0h(#(#Ifyes,describeonanattachedsheet.'}Eth(#h(# 10.0  Haveyoupaid"orwillyoubepaying"anattorneyanymoneyforservicesin 8  connectionwiththiscase,includingthecompletionofthisform?[]Yes[]No$ t(#(# 0  Ifyes,howmuch?$____________ L (#(# 0  Ifyes,statetheattorney'sname,address,andtelephonenumber: 8 (#(# 11.0  Haveyoupaid-orwillyoubepaying-anyoneotherthananattorney(suchasaparalegal   oratypist)anymoneyforservicesinconnectionwiththiscase,includingthecompletion   ofthisform?[]Yes[]Nop(#(# 0  Ifyes,howmuch?$____________H(#(# 0  Ifyes,statetheperson'sname,address,andtelephonenumber:4(#(# 12.0  Provideanyotherinformationthatwillhelpexplainwhyyoucannotpaythedocketfees 4 foryourappeal. (#(# 13.0  Statethe[cityandstate]ofyourlegalresidence.l(#(#   Yourdaytimephonenumber:(____)_______________ 0"    Yourage:________0  Youryearsofschooling:________$X"(#(#   [Lastfourdigitsof]yoursocial-securitynumber:_______