Case 3:13-cv-00346-WWE Document 2 Filed 03/14/13 Page 1 of 5

'lFD

UNITED STATES DISTRICT COt.&,.

......
DISTRICT OF
MM\ \ A 8: 23
MOTION FOR LEAVE TO PROCEED IN
PURSUANT TO 28 U.S.C. 1915

- Gifh '<"1!?

tJ\. SO !t""('VI+'''\.O
Plaintiff(s),

31SCV00346

Case No. -'"'---_ _ _ __

V.

Defendant(s) .

. .. - ..

I request

to commence this civil action without prepayment of fees, costs,

or security therefor pursuant to 28 U.S.C. 1915. In support of my request, I submit

the attached financial affidavit. and state that:
(1)
(2)
(3)

."

I am unable to pay such fees, costs, or give security therefor.

I am entitled to commence this action against the defendant(s).
I request that the court direct the United States Marshal's Service to serve
process.

Original Signature

\.(CAXh '1''-( Vl /I.}..:, 56('(" h-+; \1\.0

Name (print or
2-('- CNtV-t,S ':Ce(Y(9. u..
Street Address
i
C;J Db
City
State
Zip Code
(2.07) Hoo
2Telephone Number

v\?'

--

Rev.12/1/11

Case 3:13-cv-00346-WWE Document 2 Filed 03/14/13 Page 2 of 5

UNITED STATES DISTRICT COURT

DISTRICT OF CONNECTICUT
FINANCIAL AFFIDAVIT IN SUPPORT OF
MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS
PURSUANT TO 28 U.S.C. 1915

...'>

Plaintiff(s),

v.
IJ\ 0. vI(

Case No. ----

:r- Wv-. J

Defendant(s}.

ihc\N{d v.p.\(y

.
cA(.:J(IIccty

.:11.

CouV+

G:?<A","-y (}..lAd

Jf-

C0lA Vliy

I declare that:

(1)

I am unable to pay such fees, costs, or give security therefor.

(2)

I am entitled to commence this action against the defendant{s).

I further state that the responses I have made to the questions below relating to my
ability to pay the cost of prosecuting this action and other matters are true:
MARITAL STATUS
Married
Separated
Single
If separated or divorced, are you paying flny sUPDorf'Or any form of maintenance?
Yes
No
1:.
5 V1J(-'o rojDependents: Spouse _ _ Children #
Others # _ _
and relationship
(;tV\-,)..
Please provide the names and ages of your children. IF A CHILD IS A MINOR
(UNDER AGE 18), PLEASE -IDENTIFY THE CHILD BY INITIALS ONLY.
Name
S ,
Age 1."2Name
Age _ __
Name
Age _ _ _

=rr

J29..

-.rr

-.il

S S.

RESIDENCE
Street Address: 7-(2.. ClJ.V"\'Sl-QyY'Q. C-e...
Cityt fu\A'e\ d . State:
Zip Code: Ob <g.... 6"
Telephone: 20?'

Rev.12/1/11

HOD

_____
- 1:.7 i 'L

Case 3:13-cv-00346-WWE Document 2 Filed 03/14/13 Page 3 of 5

Owed to:
Total:
5'S3 J

na.. .1Jb

13a.V\\C p.t- AMerk,, {!... ( \ \11.

Montffiy payment '2( <tt II

()Q .

Owedto: ___________________________________________________
Total: --:-___----::-_________ Monthly payment ___________________
Annual income from property: ---'0=--___ __________________________
Other property:
Automobile: Make
A
Model _ _____ _ Year _ _
Registered owner(s) name(s): _ ___________________ __ _________
Present value of automobile: _____________________________________
Owed to:
----:--------------------------------------------Amountowed:
__________________________________________
__

tvl

Cash or Securities on hand:

Cash in banks and savings and loan associations: tJOYl. -e.
Nam es and add resses of ba n ks and
"Z/5o fS\v.dCJ fa 1 ,q={ e.)..J., (X

c:..e"""""''''>"+I_ _ _ __

Stocks or bonds'owned:
Indicate current value and name of company and number of shares of stock or identify
bonds : ______________________________________________________

'0,

N\o.v-K.1.

OBLIGATIONS:
0
Monthly rental on house or apartment:
r-";;r $'
0
( \111
')
Monthly mortgage payment on house:
$______ _ _____
otL
bill per month:
$
GI\.lEO.6-'t
Electric bill per month:
$
"'2.-'2-/. q <2?
J, ? I 2-20.l4
Phone bill per month:
$
0
e.
Car payments per month:
$
0
C,.C\.yCar insurance payments per month:
$
0
Other types of insurance payments per month $
0
A
Monthly payments to retail merchants:
$,________---,---..,,___
Please list: .clotht\<1.s,
$_ _ _.......J.=.J}
"""",.o_o__
Please list:
0
$,_______-'--_____
Monthly payments on
other outstanding
rt$__--__----::-__----:___
loans or
Please
$
500. DO
C.O(.A.vtPlease list
$____________
Any money owed to doctors, hospitals, lawyers
$ _____________
Please list:
Please list:
$_______________
Monthly paymel)t for maintenance or child support
$____
under separation or dissolution agreement:
Estimqted monthly
food:
$....;;___4-'.:.-5=-.=0:....;,.._
_ ___

moY'

Rev.12/1/11

571. &:,0

'f

:
.

Case 3:13-cv-00346-WWE Document 2 Filed 03/14/13 Page 4 of 5

EDUCATION
Please indicate the highest level of formal education you have completed:

EMPLOYMENT
If employed at present, complete the following:
Name of employer: ----'-"'' '-+-'IA--'--_ __ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Address of employer:
How long employed by present employer:
Income: Monthly
Weekly _ _ _ _ __ _ __

If self-employed state weekly wages:

What is the nature of your employment?
If unemployed at present, complete the following:
I have been unemployed since the
day of
e t
.:. 1'19')..
The name of my last employer:
t-lo.V'r4 e.f- L" l VI ..
Addre$s:
,MR Ln
16 ("'?- N""I
Qt,......-\-I n -e..s 's
Telephone #: (
)
- OtA.f--- O- \<? lA6 1he..,
The last salary or wages received:
'd-.- Q ; 060 ..<ad
't eav- .
If spouse is employed, please complete the following:
Name of employer:
How long employed: _ _ _ _ _ _ _ _ _ _ _ __
Income: Monthly
Weekly _ _ _ _ _ _ _ _ __
What is the nature of spouse's employment? _ _ _ _ _ _ _ _ _ _ __
'fc:90'O 'S-rAMI{J'S

If on welfare or receiving 'lner:RJ3lo'y'n iel it bellefits complete the following:.

I have been on welfare or receiving unemployment benefits
since:
---------I am receiving $
monthly
weekly ._ _ __
for myself and family of _A..o<::....:l"---_ _ _ _ _ . (VVI.,(s-el.(2
50""1

If receiving social security, disability qr workers' compensation benefits complete the

following:
..
I have been receiving social security, disability or workers' compensation benefits
since:
tJ/A
I am receiving $
monthly
weekly--.:....._ __
FINANCIAL STATUS
Owner of real property? Yes
If yes, description: Oh-/2.

ill No I I
' Ao

________
In whose name?
Estimated value:
Amountowed: __
Rev,12/1/11

_ _ _ _ _ _ _ _ _ _ _ _ ___

Case 3:13-cv-00346-WWE Document 2 Filed 03/14/13 Page 5 of 5

Estir,!,18ted monthly expenditure on clothing:

$_ _ _ _ _ _ __

Total amount of monthly obligations:

$ _ _Lt!.-f-I l:,\:.wk=--.L..:[

5 - ' L -

Other information pertinent to financial status: (Include stocks, bonds, savings bonds,
interests in trusts either owned or jointly owned):

PREVIOUS LITIGATION:
If you have ever filed a case in this district, provide the following information for each
case you have filed_ If you need additional space, please continue on a separate sheet.

Case Number

Disposition of Case

Case Caption

1_
2.

3_
4.
5.

Original Signature of Affiant

DECLARATION UNDER PENALTY OF PERJURY

I declare under penalty of perjury under the laws of the United-States of America that
the foregoing is true and correct to the best of my knowledge and belief.

Original Signature of Affiant

Rev.1211/11