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UNITED STATES DISTRICT COt. ,.
DISTRICT OF
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23
MOTION FOR LEAVE TO PROCEED IN
PURSUANT TO 28 U.S.C.
1915
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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
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Plaintiff(s),
v.
Case No.
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Defendant(s}. .
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cA(.:J(IIccty
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Owed to:
Total:
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J
na..
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13a.V\\C p t
AMe r k { ... ( \ \11
Montffiy payment
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EDUC TION
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
VI .
Addre s:
,MR Ln 16 ( '?-
N I
Qt ......-\--
I
n
-e..s
's
Telephone : ( ) - OtA.f--- O- \
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Estir, ,18ted
monthly expenditure on clothing:
Total amount o monthly obligations:
t .-f-I
L :[
:,\:.wk=--
5 L
Other information pert inent 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
Case Caption Disposition o Case
1_
2.
.
_
4.
5.
Original Signature o Affiant
DECLARATION UNDER PENALTY OF PERJURY
I declare under penalty o perjury under the laws o the United-States o America that
the foregoing is true and correct to the best
o my
knowledge and belief.
Original Signature o Affiant
Rev.1211/11
5
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