Gomes v. New York Public Library

Filing 17

SUPPLEMENTARY PAPERS TO MOTION [2], on behalf of Appellant Joe A. Gomes, FILED. Service date 05/18/2011 by CM/ECF.[293155][17] [11-1685]

FINANCIAL AFFIDAVIT

In Support of a Motion to Proceed In Forma Pauperis

Case Name:

Gnme-s vs. Nea) York eubUc:. Ub("a..'<',1

Docket Number:

_~-1'3S=

EMPLOYMENT

L

D

Are you now employed?
IYes
No
Name & Address of Employer:
:IDe

La Self Employed
Game s

If YES, how much do you earn per month? S_~_~~

lfNO, give month & year oflast employment
How much did you earn per month?

.f Z~M' Month

0

Ifmarried, is your spouse employed?
Yes IVI No
If YES, how much does your spouse earn per month? $

nF ("'
~~.~

No!- Ap,1! Ca.b/~";l

:::0):> _
("\)-0,.

If a minor under age 21, what is your parents' or guardian's approximate monthly i~e? :'v

$

~

Not- Irff/,' cable.

OTHER INCOME
Have you received in the past 12 months any income from a business, profession, or other form
of self-employment, or in the~ ofr~ayments, interest, dividends, retirement or annuity
payments, or other sources? l.!:J Yes UNo
If YES, give the amount received and identifY sources:
Received

Sources:

S+Oc.ks -, f?e-\-u.((l oo-±.n\le.ske.t)t

f);J..Z

CASH
Have you any cash on hand or money in savings, a prisoner trust fund account or checking
account? DYes
No
If YES, state total a~ount $ No!-

0

At¥t'ca.ble..

PROPERTY
Do you own any real estate, stock, bonds, notes, automobiles or other valuable property
Yes
No
(excluding ordinary household furnishings and clothing?)
If YES, give value and describe it:
-~

0'

Value
~ 93'

D

Description

. 4 stock BrokElfo...ge Acc.c>l..loT

DEPENDENTS

Marital status:
Total No. of Dependents:
Single
D
Married
Widowed
Separated or Divorced

o
o
D

Not'}e.__ ~ ___

List persons you actually support & your relationship

No+-

Apfhco.h/~

_____~_ _

DEBTS & MONTHLY BILLS

List all creditors, including banks, loan companies, charge accounts, etc.

Creditors:
Apt. or Home:

No}

A:fflrcahle

Total
Debt:
$
$_---­
$~-~-

ri

Monthly
Payment:

~j/
$_--­

I certify the above to be correct.

ffAbol/

Date

WARNING: A false or dishonest answer to a question in this affidavit may be punishable by
fine, imprisonment, or both.