Jacobs v. Robeson County Public Library, et al

Filing 1

MOTION for Leave to Proceed in forma pauperis filed by Sherryl Lynn Jacobs. (Attachments: # 1 Proposed Complaint, # 2 Equal Employment Opportunity Commission Forms, # 3 Proposed Summonses, # 4 Proposed Waivers, # 5 Civil Cover Sheet) (Grady, B.)

FILED
JAN 1 9 2012

Page I of 5

DENNIS PlAY:
US DIST .
ARONE, CLERK
BY
URT E

AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Fonn)

UNITED STATES DISTRICT COlJRT
for the
Southern District of North Carolina
Sherryl Lynn Jacobs

)
)
)
)
)

Plaintiff/Petitioner
v.
Robe~. Fi~_her,Robeson County,Ro~son

CtyPubLib

DefendantlRespondent

Civil Action No.

1, 12-cv/20-fL,

APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS
(Long Form)

Affidavit in Support of the Application

Instructions

I am a plaintiff or petitioner in this case and declare
that I am unable to pay the costs of these proceedings
and that I am entitled to the relief requested. I declare
under penalty of perjury that the information below is
true and understand that a false statement may result in
a dismissal of y claims.

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 that response. If
you need more space to answer a question or to explain your
answer, attach a separate sheet of paper identified with your
name, your case's docket number, and the question number.

/1'

/l

Signed: ~/ff"-~~-qI,~f.4t':trv7~.~'.L£.>~J.L

Date:

01117/2012

/

;/

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 income
amount during the past 12
months
You
Spouse

Income source

Employment
Self-employment
Income from real property (such as rental income)
Interest and dividends
Gifts
Alimony
Child support

Income amount expected
next month
You

Spouse

$

320.00 $

0.00 $

320.00 $

0.00

$

0.00 $

0.00 $

0.00 $

0.00

$

0.00 $

0.00 $

0.00 $

0.00

$

52.50 $

0.00 $

0.00 $

4.37

$

0.00 $

0.00 $

0.00 $

0.00

$

0.00 $

0.00 $

0.00 $

0.00

$

250.00 $

0.00 $

250.00 $

0.00

Page 2 of 5
AO 239 (01109) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)

Retirement (such as social security. pensions, annuities,

Unemployment payments
Public-assistance (such as welfare)
Other (specify):

Total monthly income:
2.

0.00 $

0.00 $

0.00

$

123.00 $

1,173.00 $

123.00 $

1,173.00

225.00 $

0.00 $

0.00 $

0.00

$

insurance payments)

0.00 $

0.00 $

0.00 $

0.00 $

0.00

$

Disability (such as social security,

$

$

insurance)

0.00 $

0.00 $

0.00 $

0.00

$

970.50 $

1,173.00 $

693.00 $

1,177.37

List your employment history for the past two years, most recent employer fIrst.

(Gross monthly pay is before taxes or

other deductions.)

Employer

Address

DOD Schools

Fort Bragg NC School System

Dates of employment

I

Oct 2010 to Present (Hourly Pay

Gross
monthly pay
$

10.50

$

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

Address

N/A

N/A

Dates of employment

N/A

Gross
monthly pay
$

0.00

$

$

4.

How much cash do you and your spouse have? $

2,003.28

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

Type of account

Amount you have

Amount your
spouse has

USAA

JOINT CHECKING

$

2,003.28 $

0.00

LUMBEE BANK

JOINT INVESTMENT

$

7,000.00 $

0.00

FIRST SOUTH BANK

JOINT CHECKING(EMER)

$

675.00 $

0.00

If you are a prisoner, 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.

Page 3 of 5
AD 239 (01109) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Fonn)

5.

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

Assets owned by you or your spouse
Home (Value)

$

65,000.00

$

9,000.00

$

3,500.00

$

5,000.00

Other assets (Value)

$

0.00

Other assets (Value)

$

0.00

Other real estate (Value)
Motor vehicle #1 (Value)
Make and year: KIA 2007
Model:

Rondo

Registration #: KNAFG525477043394
Motor vehicle #2 (Value)
Make and year: Dodge 2005
Model:

Dakota

Registration #: 1D7HE28KX5S246321

6.

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

Amount owed to you

Person owing you or your spouse
money
$

N/A

Amount owed to your spouse
0.00

$

$

7.

$

$

0.00

$

State the persons who rely on you or your spouse for support.

Name (or, ifunder 18, initials only)

Relationship

Age

Page 4 of 5
AD 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Fonn)

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

Your spouse

Rent or home-mortgage payment (including lot rentedfor mobile home)
Are real estate taxes included? o Yes o No
Is property insurance included? o Yes o No

$

0.00 $

0.00

Utilities (electricity, heatingjuel, water, sewer, and telephone)

$

197.99 $

197.99

Home maintenance (repairs and upkeep)

$

32.50 $

32.50

Food

$

40.00 $

20.00

Clothing

$

25.00 $

0.00

Laundry and dry-cleaning

$

20.00 $

10.00

Medical and dental expenses

$

10.00 $

0.00

Transportation (not including motor vehicle payments)

$

200.00 $

185.00

Recreation, entertainment, newspapers, magazines, etc.

$

3.50 $

0.00

Homeowner's or renter's: Homeowner's

$

65.00 $

65.00

Life:

$

0.00 $

0.00

Health:

$

0.00 $

0.00

$

50.00 $

125.50

$

0.00 $

0.00

$

0.00 $

0.00

Motor vehicle:

$

0.00 $

0.00

Credit card (name):

$

0.00 $

0.00

Department store (name):

$

0.00 $

0.00

Other:

$

0.00 $

0.00

$

0.00 $

0.00

Insurance (not deductedfrom wages or included in mortgage payments)

Motor vehicle:

Both Vehicles

Other:
Taxes (not deductedfrom wages or included in mortgage payments) (specify):
Installment payments

Alimony, maintenance, and support paid to others

Page 5 of 5
AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Fonn)

Regular expenses for operation of business, profession, or farm (attach detailed
Other (specify):
Total monthly expenses:
9.

$
$

$

643.99

$

635.99

Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the
next 12 months?
DYes

10.

$
$

statement)

if

No

If yes, describe on an attached sheet.

Have you paid - or will you be paying - an attorney any money for services in connection with this case,
including the completion of this fonn? if Yes a No
If yes, how much? $
~ 25~~__~_

If yes, state the attorney's name, address, and telephone number:

The Angel Law Firm. PLLC

PO Box 692

Harrisburg, NC 28075

[phone]
11.

Have you paid - or will you be paying - anyone other than an attorney (such eLf a paralegal or a typist) any money
for services in connection with this case, including the completion of this fonn?
a Yes if No
Jfyes, how much? $
~_~
_

If yes, state the person's name, address, and telephone number:

12.

Provide any other infonnation that will help explain why you cannot pay the costs of these proceedings.
Due to political pressures the attorney named above is the only one who would even talk to me about this
case and his office is over 185 miles one way from my home. He reviewed my case and told me that since
the recovery would be limited that he would have to charge me $300.00 per hour to work on the case. At
those rates I would have to sell my home and become a burden on society.

13.

Identify the city and state of your legal residence.
Orrum, North Carolina

Your daytime phone number:

Your age:

53

Your years of schooling:

Last four digits of your social-security number:

14