Name, Address, 

E-mail, & Phone 

FILED2CH111' '1515:531JSDC~ 

UNITED STATES DISTRICT COURT 

DISTRICT OF OREGON 

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I 

Case No.: 3 l :.5 c v--7 1'5 - >T Plaintiff( s ), 

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v. PQI .'( e c.'1,~ R.. e 

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Defendant(s ). 

MOTION FOR APPOINTMENT 

OF PRO BONO COUNSEL 

I, _ _.R___.v.__~....__,_(-'-v_J-;;__W;;_--=-( .. ).___,±_· ---"'move for the appointment of pro bono counsel. 

To support this motion, I declare under penalty of perjury that (check one): 

0 I have been granted, or have applied for, permission to proceed in forma pauperis. 

0 I have attached an affidavit demonstrating my inability to pay the cost of an attorney. 

I have made the following diligent efforts to obtain legal counsel but have been unsuccessful because of 

my poverty (describe below): _ , ...L.__. 

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I need appointed counsel to assist me because (describe below): r ·j , J o , 5 rlK~ 0 

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5 I '2..u / 2-o f5 

Signature 

j<._ 0 .be vf we):/-

Date 

Printed Name 

Case 3:15-cv-00715-ST Document 8 Filed 05/20/15 Page 1 of 4
' 

AFFIDAVIT IN SUPPORT OF 

MOTION FOR APPOINTMENT OF PRO BONO COUNSEL 

I answer the following questions under penalty of perjury: 

1. Are you currently incarcerated? DYes .J?'No 

If you answered yes, where are you are incarcerated? ---------------

2. Are you currently employed? D Yes j(No 

If you are employed: 

List your employer's name: 

List your employer's address: 

Amount of take-home pay: $ 

If you are not employed: 

Name your last employer: - Last employer's address: 

Date of last employment: ____, 

Amount of take-home pay: $ 

per _____ (hour, day, week, month) 

per _____ (hour, day, week, month) 

3. Is your spouse or significant-other employed? D Yes D No Q-Not Applicable 

Name of employer: 

Employer's address: 

Date of last employment: 

Amount of take-home pay: $ ____ per _____ (hour, day, week, month) 

4. Have you received money from any of the following sources in the last 12 months? 

• Business, professions, or other self-employment: 

0 Yes Amount Received: $ 

---- Amount expected in future: $ ___ _ 

@"No 

• Rent payments, interest, or dividends: 

0 Yes Amount Received: $ ___ _ Amount expected in future: $ ___ _ 

Case 3:15-cv-00715-ST Document 8 Filed 05/20/15 Page 2 of 4
\ 

• Pensions, annuities, or life insurance payments: 

c-: ,.., /! ,. 

0 Yes Amount Received: $ ---- Amount expected in future: $ ___ _ 

~No 

• Disability or workers compensation payments: 

~Yes Amount Received:$ 2: IS Amount expected in future: $ ___ _ 

0 No 

• Gifts or inheritances: 

0 Yes Amount Received: $ ___ _ Amount expected in future: $ ___ _ 

-~No 

• Any other sources: .{o~ -/-1.11'~~~. 1iJc ... i/J 

~Yes Amount Received:$ I 3~ Amount expected in future: $ ___ _ 

0 No 

5. Do you have cash or savings accounts, including prison trust accounts? 

8" Yes Total amount:$ S f S' 

0 No 

6. Do you own any real estate, stocks, bonds, securities, other financial instruments, 

automobiles, or other valuable property? 1'1 Yes (describe below) D No 

Type of Asset Brief Description Estimated Value 

c·v\ v loll( PV ;s 

7. Do you have any other assets? D Yes (describe below))(.!.. No 

Type of Asset Brief Description Estimated Value 

Case 3:15-cv-00715-ST Document 8 Filed 05/20/15 Page 3 of 4
' 

8. Do you have monthly expenses, including housing, transportation, utility, judgments, loan 

payments, or other regular expenses? ~es (describe below) 0 No 

Expense Description Estimated Monthly Payment 

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9. List the persons (or, if under 18, initials only) who are dependent on you for support: 

Name or Relationship Amount of Monthly Support 

Minor's Initials (Spouse, child parent, etc.) Your Provide 

V1 c>l/L..0 

10. Do you have any debts or financial obligations? ~Yes (describe below) 0 No 

'v\) [? &. "' K 1( Z. 10°0 DepT 

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Signature Date 

r o J,. c v+- -vv-<-;-JPrinted Name 

Case 3:15-cv-00715-ST Document 8 Filed 05/20/15 Page 4 of 4