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MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS
I, . .-zlaze.
'I Pr6J~f-. f-tfZ> I s-rrt do hereby request leave to
proceed in forma pauperis ~d state unaer oath that I am unable to pay the costs for commencement of this
_ _ _ _ _ _ _ _ _ action, or to give security therefor, and that I believe I am entitled to redress.
I further state the follw~ng: ·/
I am not employed ( i~·
Imnemployedh;: ~ ~~(e/ Jkrr0-{;pWiJfb-,//
and my salary is $ _ _ _ _ _ _ _ _ _ _ per---'---~-----·
I have no other sources of income except the following (include public assistance, social security
disability, or any other income not included above employment and state the amount):
I have $_ _ _ _ _ (§
___,. _,______ IN CASH.
I have the following funds in the bank:
NAME OF THE BANK TYPE OF ACCOUNT AMOUNT
- J //}I j_f ,..--- $ \'?\
.,-_ ....... /'""'
$
~
$
I own the following valuable property (include real estate, stocks, bonds, notes, automobiles, and other
valuable property, but exclude ordinary household furnishings and clothing):
VALUE
$
$
$
I have the following debts: