Riches v. Karr et al

Filing 1

Riches v. Karr et al

Doc. 1

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

Document 1

Filed 09/20/2007

Page 1 of 2

wEslEfri-r
Uhrrrsn SrernsDlsrmcr CouRr
t -ie s4cr )

2 sEP 02m7
DFUIYq.HK

D i s t r i c t o r Al/<Ao*5A5**'*n**
A P P L I C A T I O NTO PROCEED W I T H O U T PREPAYMENTOF F E E SAND AI'$IDAVIT

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

l l 6 l l n ' l"1n.K Karr *ol, FtL.
Defendant

.ASENUMBER: 0]-

l-t Ol

dcclare that I am the (cheokappropriate box) ffpctitioner/plaintiff/movant tr other i n thc above-entitlcd proceeding; in supporlofmy request proceetl that withoutprepayment to offees or costs u n d e r28 USC $1915I dcclare I amunable paythe costs that to oftheseproceedings thatIarn efltitledto therelief and s o u g h tin the complaint/petitioni motion., I n support ofthis application, answer following questions I the undcrpenaltyof perjury: i. Are you currentlyincarcoratcd? d Yes I f "Yes," statethe placeof your incarcemtion A r e you employed the institution at I \/r7 tr No (If ,.No," go to parl ?)

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

2.

A t t a c ha 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 a n daddress 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 a n dpayperiodandthenameantd 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

I f t h e answerto anyofthe above "Yes," desoribc, the following page,eachsource moneyand statethe is on of a m o u n treceivcdandwh8tyou 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 I f "Yes," statethe total amount.

! Yes

r1rqo

5.

Ilo yori own aly real estate, stocks, bonds, otherfinancialinskuments, gecuritics, or autofirobiles irnyother t h i n e of value? E Yes EI No I f "Yes," describc propertymd stflteits value. thc

6.

List thc persons who aredepcndent you for support, on statoyour rclationship eachpcrsonand indicate to h o w 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 ( T o 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

o n account his,ther to creditat (nameof

. I fluther oortifu theapptioanr the rhar has
and the

f o l l o w i n g securities his,4rcr uedit: to I iiirther certifythat during thepastsix monthsthe applicant's average balanoe $ was

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

S T G N A T U R E ATITHORIZEI] OF OFFICER