AO 239 (Rev. 12/13) (INND Rev. 6/14)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA

Hyouan Stewart Bey

[Yu fre the plaintiff. Type or print your namd on the
linelabove. If there is more than one plaintiff each
‘ou must complete a separate form.)

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Stok alice 1:
nant ja Cause No. Poecian
smal Security ade twrtte ste H_pasen ) Ef you are filing this in a current put thegase

—t = ) number on the line above. If this is astew case, leave
[You are suing the defendant(s). Type or print ONLY it blank, The clerk will provide the number when the
the name of the FIRST defendant on the live above.] ) case is filed.]

/ PETITION TO PROCEED
WITHOUT PRE-PAYMENT OF FEES AND COSTS

I declare that I am not a prisoner and that I cannot pay the full filing fees and costs of this

civil lawsuit or give security because of my poverty. I believe that my claims have merit
and I petition the court to proceed without pre-payment of court fees and costs.

1. Are you employed?
xo

QO YES, my gross earnings (before deductions for taxes, etc.) are $ per month.

(accent )

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Wes, my spouse's gross earnings (before deductions for taxes, etc.) are $. Wem per month.

3. Have yu or your spouse received any money inthe past 12 months from any source other than
« Amployment?
NO

OO yes

From whom?

2. Are you married?

Ono

How often? How much?

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‘AQ 239 (Rev. 12/13) (INND Rev. 6/14)

4. Are you financially dependent on someone other than your spouse for support?

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5. How much cash do you and your spouse have? $. | f SO

6. Do you or your spouse have money in a checking, savings, Certificate of Deposit, or any other account?

Ong

Bes.
Name of Financial Institution Type of Account How Much?
fartners Cicst Saunas 1,050

7. What is the value of your and your spouse’s real estate, cars, jewelry, stocks, bonds, and other valuable

property or investments? §. go >

8. Do you have any dependents?

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es, I support 1¢ chita, / children who is/are under 18 years of age.

List any adult (other than your spouse) whom you support:
Name Age | Relationship How Much?

9. Please provide any other information that should be considered in raed your petition,
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I declare under oe) of perjury that the foregoing is true.
Spy

Today's Date: Y ae # Your Signature:



V. VERIFICATION AND SIGNATURE

A ; G ‘ Initial Each Statement and Sign at the Bottom

clerk) for each defendant I am suing, including full name, job title and work

Wise J have included two properly completed summons forms (available from the
2)
g i ddress.

ALS y I have included one properly completed process receipt and return form

Ae (USM-285) (available from the U.S. Marshal) for each defendant I am suing.

A yor’ 5 . p addition to this complaint with an original signature, I have included one
0.

py of this complaint for each defendant and one extra for the court.

G ‘ Pave included full payment of the filing fee OR attached a properly
ye SO petition to proceed in forma pauperis (available from the clerk).

6 agree to promptly notify the clerk of any change of address.
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have read all of the statements in this complaint. /Do not forget to keep a copy

for your records.]

Mi : %
ait 3 I declare under penalty of perjury that the foregoing is true and correct.
Signed this ww, g day of Aye. / , 20.144.

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