Taylor v. Leu et al

Filing 85

ORDER DENYING REQUEST TO PROCEED IN FORMA PAUPERIS ON APPEAL; FORM 4 re 84 - Signed by JUDGE SUSAN OKI MOLLWAY on 10/18/2016. Motion terminated: 84 MOTION for Leave to Appeal in forma pauperis filed by Sar ah Margaret Taylor. "The Clerk of Court is ordered to (1) notify the parties and the Ninth Circuit of the denial of Taylor's request to proceed in forma pauperis ; and (2) send a copy of this order to Tayl or via e-mail." (Attachments: # 1 Form 4) (emt, )CERTIFICATE OF SERVICEParticipants registered to receive electronic notifications received this document electronically at the e-mail address listed on the Notice of Electronic Filing (NEF). Sarah Margaret Taylor served via e-mail at [e-mail] and by first class mail at the address of record on October 18, 2016. The Ninth Circuit Court of Appeals served electronically, via Notice of Electronic Filing (NEF) on October 18, 2016.

Form 4.

Affidavit Accompanying Motion for Permission to Appeal In Forma Pauperis

UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT

Appellant(s) or Petitioner(s)
Case No.

v.
Appellee(s) or Respondent(s)

Affidavit in Support of Motion

Instructions

I swear or affirm under penalty of perjury that, because of
my poverty, I cannot prepay the docket fees of my appeal
or post a bond for them. I believe I am entitled to redress. I
swear or affirm under penalty of perjury under United
States laws that my answers on this form are true and
correct. 28 U.S.C. sec. 1746; 18 U.S.C. sec. 1621.

Complete all questions in this application and then sign it. Do
not leave any blanks: if the answer to a question is "0," "none,"
or "not applicable (N/A)," write in that response. If you need
more space to answer a question, attach a separate sheet of
paper identified with your name, your case's docket number, and
the question number.

Signed:

Date:

My issues on
appeal are:

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1.

For both you and your spouse estimate the average amount of money received from each of the
following sources during the past 12 months. Adjust any amount that was received weekly, biweekly,
quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts
before any deductions for taxes or otherwise.
Average monthly amount during
the past 12 months
Income Source

You

Amount expected next month

Spouse

You

Spouse

Employment

$

$

$

$

Self-Employment

$

$

$

$

Income from real property
(such as rental income)

$

$

$

$

Interest and Dividends

$

$

$

$

Gifts

$

$

$

$

Alimony

$

$

$

$

Child Support

$

$

$

$

Retirement (such as social security,
$
pensions, annuities, insurance)

$

$

$

Disability (such as social security,
insurance payments)

$

$

$

$

Unemployment Payments

$

$

$

$

Public-Assistance (such as welfare) $

$

$

$

Other (specify)

$

$

$

$

TOTAL MONTHLY INCOME:

$

$

$

$

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2.

List your employment history for the past two years, most recent employer first.
(Gross monthly pay is before taxes or other deductions.)
Employer

Dates of
Employment

Address

Gross Monthly
Pay

From
$

To
From

$

To
From

$

To
From

$

To

3.

List your spouse's employment history for the past two years, most recent employer first.
(Gross monthly pay is before taxes or other deductions.)
Employer

Dates of
Employment

Address

Gross Monthly
Pay

From
To
From
To

$

$

From
To

$

From
To

-3-

$

4.

How much cash do you and your spouse have?

$

Below, state any money you or your spouse have in bank accounts or in any other financial institution.
Financial Institution

Type of Account

Amount You Have

Amount Your Spouse
Has

$

$

$

$

$

$

$

$

If you are a prisoner seeking to appeal a judgment in a civil action or proceeding, you must attach a
statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances
during the last six months in your institutional accounts. If you have multiple accounts, perhaps because
you have been in multiple institutions, attach one certified statement of each account .
5.

List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary
household furnishing.
Other Real Estate

Value

Home

$

$

Motor Vehicle 1: Make & Year

Value

Registration #

Model

Value
$

Motor Vehicle 2: Make & Year

Model

Value

Registration #
$

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Value

Other Assets

$
$
$

6.

State every person, business, or organization owing you or your spouse money, and the amount owed.
Person owing you or your spouse

Amount owed to you

Amount owed to your spouse

$
$

$

$

7.

$

$

State the persons who rely on you or your spouse for support. If a dependent is a minor, list only the
initials and not the full name.

Name

Relationship

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Age

8.

Estimate the average monthly expenses of you and your family. Show separately the amounts paid by
your spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually
to show the monthly rate.
You

Spouse

Rent or home-mortgage payment (include lot rented for mobile home)
- Are real estate taxes included?
Yes
No
- Is property insurance included?
Yes
No

$

$

Utilities (electricity, heating fuel, water, sewer, and telephone)

$

$

Home maintenance (repairs and upkeep)

$

$

Food

$

$

Clothing

$

$

Laundry and dry-cleaning

$

$

Medical and dental expenses

$

$

Transportation (not including motor vehicle payments)

$

$

Recreation, entertainment, newspapers, magazines, etc.

$

$

Insurance (not deducted from wages or included in mortgage payments)
- Homeowner's or renter's......................................................................................................... $

$

- Life.......................................................................................................................................... $

$

- Health...................................................................................................................................... $

$

- Motor Vehicle......................................................................................................................... $

$

- Other:

$

$

$

$

- Motor Vehicle......................................................................................................................... $

$

- Credit Card

$

$

$

$

- Motor Vehicle......................................................................................................................... $

$

Taxes (not deducted from wages or included in mortgage payments)
Specify:
Installment payments

(name):

- Department Store

(name):

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Alimony, maintenance, and support paid to others

$

Regular expenses for the operation of business, profession, or farm
(attach detailed statement)

$

$

Other (specify)

$

$

Total Monthly Expenses: $
9.

$

$

Do you expect any major changes to your monthly income or expenses or in your assets or liabilities
during the next 12 months?
No

Yes

If yes, describe on an attached sheet.
10.

Have you spent--or will you be spending--any money for expenses or attorney fees in connection with
this lawsuit?
No

Yes

If yes, how much? $
11.

Provide any other information that will help explain why you cannot pay the docket fees for your
appeal.

12.

State the city and state of your legal residence.
State

City
Your daytime phone number (ex., 4153558000):
Your age:

Your years of schooling:

Last four digits of your Social Security Number (ex.,6789):

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