Joe Meyer v. United States

AFFIDAVIT OR DECLARATION IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS ’Z—-----------f—- ’ am the petitioner in the above-entitled case. In support of S , X?r “/Orma W™, I state that because of my poverty I am unable to pay the costs of this case or to give security therefor; and I believe I am entitled to redress. 1. For both you and your spouse estimate the average amount of money received from each of tXw Klngm0UrCeS ?Tng the paSt 12 months- AdJust W ^at was received or annuallY to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. Income source Average monthly amount during Amount expected the past 12 months next month You 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 $__________ $__________ <R________ __ $ (such as welfare) Other (specify): Total monthly income: $ 33<3C> $