Gomes v. New York Public Library

Filing 2

MOTION, to proceed in forma pauperis, on behalf of Appellant Joe A. Gomes, FILED. Service date 04/28/2011 by CM/ECF.[275578] [11-1685]

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF NEW YORK.

..1L Civ. b3"7

(In the space above enter the full name(s) ofthe p/aintijJ(s)/petitioner(s).)

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REQUEST TO PROCEED
IN FORMA PAUPERIS
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('m-roe S
, (print or type your name) am the plaintiff/peti~ner in
above entitled case and I hereby request to proceed in forma pauperis on appeal and without bei~ required
to prepay fees or costs or give security. I state that because of my poverty I am unable to pay the costs of
said proceeding or to give security therefor, and that I believe I am entitled to redress.

I,

JOe. A.

The issues I desire to present on appeal are the following:

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If you are presently employed:
a) give the name and address of your employer
b) state the amount of your earnings per month

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If you are NOT PRESENTLY EMPLOYED:
a) state the date of start and termination of your last employment
b) state your earnings per month
YOU MUST ANSWER THIS QUESTION EVEN IF YOU ARE INCARCERATED.

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Have you received, within the past twelve months, any money from any source? If so, name the
source and the amount of money you received.

a) Are you receiving any public benefits?
b) Do you receive any income from any other source?

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Do you own any apartment, house, or building, stock, bonds, notes, automobiles or other property?
If the answer is yes, describe the property and state its approximate value.

o No.

6.

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Do you have any money, including any money in a checking or savings account? Ifso, how much?

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5.

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Do you pay for rent or for a mortgage? If so, how much each month?
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7.

List the person(s) that you pay money to support and the amount you pay each month.

8.

State any special financial circumstances which the Court should consider.

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