Name, Address, 

E-mail, & Phone 

FILfD24 FEB '1614:411J3DC-i)Rp 

UNITED STATES DISTRICT COURT 

f ta f-e ,,/} 0 /&ff eJ Y'--

Defendant( s ). 

DISTRICT OF OREGON 

J!~o.: CV-0 341 

MOTION FOR APPOINTMENT 

OF PRO BONO COUNSEL 

, move for the appointment of pro bono counsel. 

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

[8"" I have been granted, or have applied for, permission to proceed in forma pauperis. 

~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 

SI 

my poverty (describe below): ;J 

w-e-11+~ /3,{)t~ JfU ~ krie111fj /?t_q~f5 o/ CJ/<. ;grf-la.tv" kJf~f":J 

"'>1 """f.; L~r I A',(, c.,/fe) a+- le" fl'- 7£} kk/je v 7 ~'I- cP f /' h.M e 

lo(!) C> )_. 

Case 3:16-cv-00341-SI Document 3 Filed 02/24/16 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? D Yes DKNo 

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

2. Are you currently employed? D Yes ~o 

If you are employed: 

List your employer's name: 

List your employer's address: 

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

If you are not employed: 

Name your last employer: rJe41'!1? C-v"tl l-"-l fJ..e?<PUvU f 

' Last employer's address: 

Date of last employment: 

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

3. Is your spouse or significant-other employed? D Yes D No %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: 

D Yes Amount Received: $ ___ _ 

~No 

• Rent payments, interest, or dividends: 

o;ves 

~No 

Amount Received: $ ___ _ 

Amount expected in future: $ ___ _ 

Amount expected in future: $ ___ _ 

Case 3:16-cv-00341-SI Document 3 Filed 02/24/16 Page 2 of 4
• Pensions, annuities, or life insurance payments: 

D Yes Amount Received: $ 

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

~No 

• Disability or workers compensation payments: 

D Yes Amount Received: $ 

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

~o 

• Gifts or inheritances: 

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

¥No 

• Any other sources: ., 

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

";8('No 

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

D Yes Total amount: $ 

----

~o 

6. Do you own any real estate, stocks, bonds, securities, other financial ~s~ents, 

automobiles, or other valuable property? D Yes {describe below) ~o 

Type of Asset Brief Description Estimated Value 

7. Do you have any other assets? D Yes (describe below) ~o 

Type of Asset Brief Description Estimated Value 

Case 3:16-cv-00341-SI Document 3 Filed 02/24/16 Page 3 of 4
8. Do you have monthly expenses, including housing, transportati<?n, !!,Plity, judgments, loan 

payments, or other regular expenses? D Yes (describe below) ~No 

Expense Description Estimated Monthlv Pavment 

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 

10. Do you have any debts or financial obligations? D Yes (describe below) ~o 

Date 

Case 3:16-cv-00341-SI Document 3 Filed 02/24/16 Page 4 of 4