WPC a?ϙ#Uդ~O1USV,w'2ʦT*n6%b랥,,8ou^EUfٖ/@3[dh(A*ɨfj;zFUs,zaʾ|@:om\t@>[S=džh[*֋Z̍if^X~UqP|d_S2?ł!ҟ,$l[ԘHԉ6 rhji# % f 0( U(N a ^  w 4! 5 D mF ] #   u ;NYYf[] 0Da++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ B ? B*\ BB B- B*\\AO-OAHR\OAHR-CANON-3-224-Q0X($(hH  Z6Times New Roman RegularTABLE AcU/s YH/|,}&Suite83|xULevel 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5 AO USM     \R3' Letter\  (3$ !  TABLE B d&p Pd d>Thin/Thick 2[ -d d)Hairline d&0 d d !  _XB*Vddd Xdd Xdd X%%,$$ ,$$ ,$$ ,g$$ , $$ ,$$ ,$$ ,P$$ ,4$$ ,~$$ ,$$ ,$$ ,$$ ,C$$ ,$$ ,0$$ ,$$ ,$$ ,b$$ ,$$ ,[$$ +  8. 8lXX.AO240(Rev.10/03) _hN/   H_ Gh6$~h G Gh6$~h G XN/~ H h X  A>lUnitedStatesDistrictCourt XN/    XuA _VN/   _XpXu  @6$ V @  Districtof GV6$  G  XN/    V tX SI/  t  S QG5 " Q _ ND* )   N 7-  7 @6$  @ OXXpAPPLICATIONTOPROCEED#XpXO# SI*   S  Plaintiff @6$  @ QG500  Q OXXpWITHOUTPREPAYMENTOF#XpXO # XN/    X  V.uXXp QG5  vv  Q 7-  7 #XpXu #OXXpFEESANDAFFIDAVIT#XpXO # XN/     hX 7-  7 7-  7 dZ@ vv h   d  QG5T t    Q 7-h  7 E;!h   E 7-T t  7 7-T t  7uXXpCASENUMBER:#XpXuq# @6$T t  @ SI*T t   S  Defendant @6$@`   @ XN/@`    X TJ/,L    T&n %XXpIXpX %&n, DV3!8  D  @6$8 V   @declarethatIamthe(checkappropriatebox) TJ/8    dT =3!$  = TJ/$! d  T& =3!h" =petitioner/plaintiff/movant <2$h# <& =3!h$ =other XN/h%   tX XN/Tt& t  Xintheaboveentitledproceeding;thatinsupportofmyrequesttoproceedwithoutprepaymentoffeesorcosts SI/'   S  under28USC1915IdeclarethatIamunabletopaythecostsoftheseproceedingsandthatIamentitledtotherelief ( soughtinthecomplaint/petition/motion. SI*)  xS XN/* x  XInsupportofthisapplication,Ianswerthefollowingquestionsunderpenaltyofperjury: XN/$+   xX wm/, x   ?1?w1. ^TBh-  ?1 ? ^Areyoucurrentlyincarcerated? @6$h. @&  #&n %XXps#XpX %&n  A7%h/ AYes @6$h0 @&  XpXXXp  A7%h1 ANo @6$h2 @(If No,gotoPart2) XN/h3   tX XN/Tt4 t  X @6$5 @If Yes,statetheplaceofyourincarceration GV6$6  G XN/7  V  tX XN/8 t  X @6$(H9 @Areyouemployedattheinstitution? GV6$(H: G  @6$(H; V  @ЀDoyoureceiveanypaymentfromtheinstitution? CV2$(H<  C  UK,(H=   V tU XN/4> t  X @6$? @  Attachaledgersheetfromtheinstitution(s)ofyourincarcerationshowingatleastthepast six months XN/@   X @6$zA @transactions. XN/zB   xX xn/fC x   @2.@x2. _UCD  @2. @ _Areyoucurrentlyemployed? @6$E @&  XpXXXp  A7%F AYes @6$G @&  XpXXXp  A7%H ANo XN/I   tX SI/J t  S @6$>^K @a. @6$>^L @  Iftheansweris Yes,statetheamountofyourtakehomesalaryorwagesandpayperiodandgivethename >^M andaddressofyouremployer. SI** JN  S 7-$!6O 7 J@&!6P   J @6$"!Q @b. @6$"!R @  Iftheansweris No,statethedateofyourlastemployment,theamountofyourtakehomesalaryorwages "!S andpayperiodandthenameandaddressofyourlastemployer. SI*#!T  S 7-$$"U 7 oe&$"V    @3.@o3. _UC&$W  @3. @ _Inthepast12twelvemonthshaveyoureceivedanymoneyfromanyofthefollowingsources? XN/&$X   tX XN/'%Y t  X @6$($&Z @a. @6$($&[ @Business,professionorotherselfemployment @6$($&\ @& @6$($&] @Yes @6$($&^ @&  XpXXXp  A7%($&_ ANo XN/($&`   X @6$('a @b. @6$('b @Rentpayments,interestordividends @6$('c @&  XpXXXp  A7%('d AYes @6$('e @&  XpXXXp  A7%('f ANo XN/('g   X @6$)'h @c. @6$)'i @Pensions,annuitiesorlifeinsurancepayments @6$)'j @& @6$)'k @Yes @6$)'l @&  XpXXXp  A7%)'m ANo XN/)'n   X @6$*(o @d. @6$*(p @Disabilityorworkerscompensationpayments @6$*(q @& @6$*(r @Yes @6$*(s @&  XpXXXp  A7%*(t ANo XN/*(u   X @6$+)v @e. @6$+)w @Giftsorinheritances @6$+)x @&  XpXXXpXpXXXpXpXXXp  A7%+)y AYes @6$+)z @&  #XpXXXp2#XpXXXpXpXXXpXpXXXp  A7%+){ ANo XN/+)|   X @6$,*} @f. @6$,*~ @Anyothersources @6$,* @& @6$,* @Yes @6$,* @& @6$,* @No SI/,*   S @6$-+ @ ND*-+  N @6$x., @  Iftheanswertoanyoftheaboveis Yes,describe,onthefollowingpage,eachsourceofmoneyandstatethe x., amountreceivedandwhatyouexpectyouwillcontinuetoreceive.:0.d/- 0  :*Vd1d$$ $$ $$ g$$ g $$ $$ $$ P$$ P4$$ 4~$$ ~$$ $$ $$ C$$ C$$ 0$$ 0$$ $$ b$$ b$$ [$$ [V%%,$$ ,$$ ,$$ ,$$ ,$$ ,$$ ,h$$ ,$$ ,Q$$ ,$$ ,$$ ,$$ ,$$ +  8.  8lXXpԀAO240Reverse(Rev.10/03) _hN/    H_ Gh6$xh G TJ/x H h  xTXpXllXXp =3!  =#XpXlm=# TJ/ x   T 4*!8X 4 KA&8X    K =3!  = tj/      @4.@t4. \R@    @4. @ \Doyouhave any cashorcheckingorsavingsaccounts? <2$   <& 9/!   9Yes 9/!   9& 9/!  9No QG,    Q =3!   = TJ/     T =3!  =If Yes,statethetotalamount. GV6$  G @6$ V @ XN/     X oe/v      @5.@o5. \R@b   @5. @  \Doyouownanyrealestate,stocks,bonds,securities,otherfinancialinstruments,automobilesoranyother OE*b    O =3!Nn  =thingofvalue? <2$Nn  <& =3!Nn  =Yes <2$Nn  <& =3!Nn  =No TJ/Nn    T =3!:Z   = TJ/:Z     T =3!&F!  =If Yes,describethepropertyandstateitsvalue. TJ/&F"    T 4*!2# 4 KA&2$    K =3!%  = oe/&     @6.@o6. \R@'  @6. @  \Listthepersonswhoaredependentonyouforsupport,stateyourrelationshiptoeachpersonandindicate ( howmuchyoucontributetotheirsupport. OE*r)   O 4*!^~* 4 KA&^~+    K =3!,  = XN/-     XIdeclareunderpenaltyofperjurythattheaboveinformationistrueandcorrect. XN/.     X _VN/ /    _  <2$p$"0 V < DV3!p$"1 D XN/p$"2  V X  ð XXpDate <2$\%|#3  < =3!\%|#4 =  SignatureofApplicant XN/\%|#5     X SI/ &,$6     SXpX ð   NOTICETOPRISONER: APrisonerseekingtoproceedwithoutprepaymentoffeesshallsubmitanaffidavit )'7 statingallassets.Inaddition,aprisonermustattachastatementcertifiedbytheappropriateinstitutionalofficer *(8 showingallreceipts,expenditures,andbalancesduringthelastsixmonthsinyourinstitutionalaccounts.Ifyouhave n+)9 multipleaccounts,perhapsbecauseyouhavebeeninmultipleinstitutions,attachonecertifiedstatementofeach Z,z*: account. SI*F-f+;    S?532.R,<     ?'X,X%XX'