9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12
months?

OYes No If yes, describe on an attached sheet.

10. Have you paid — or will you be paying ~ an attorney any money for services in connection with this case, including the
completion of this form?

OYes BINo If yes, how much: $

If yes, state the attorney’s name, address, and telephone number:

11. Have you paid — or will you be paying — anyone other than an attorney (such as a paralegal or a typist) any money for
services in connection with this case, including the completion of this form?

OYes &INo If yes, how much? $

If yes, state the person’s name, address, and telephone number

12. Provide any other information that will help explain why you cannot pay the docket fees for your appeal.

13. State the address of your legal residence.

Your daytime phone number: a ,

Your age: __ Your years of schooling: 20

Your Social Security number:



Motion for
Permission to Appeal In Forma Pauperis and Affidavit

United States Court of Appeals for the Eleventh Circuit

Shérete L. RusSell-Browe Court of Appeals No. 10-14328-D
v. District Court No. 1:09-cv-0025'

Chi esi 4 Floncia, Bcatct of Tutte S$ d¢al

GRJ

Instructions: Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a
question is “0,”, “none,” or “not applicable (N/A),” write in that response. If you need more space to answer a question or
to explain your answer, attach a separate sheet of paper identified with your name, your case’s docket number, and the
question number.

Affidavit in Support of Motion

I swear or affirm under penalty of perjury that, because of my poverty, I cannot prepay the docket fees of my appeal
or post a bond for them. I believe I am entitled to redress. I swear or affirm under penalty of perjury under United
States laws that my answers on this form are true and correct. (28 U.S.C. § 1746; 18 U.S.C. § 1621.)

; 5 _
| D
Date: 10/01/2010 Signed: Ui. K. Ciniu-dr—

My issues on appeal are: Awtii-cl otoried’s fe 68 Wid Cosh as Gonchar cf AiSpnicsal
1. For both you and your spouse, estimate the average ahount of money received from each of thefollowing
sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semi-
annually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for

taxes or otherwise.

Income Source Average monthly amount Amount expected next month

during the past 12 months

You Spouse You Spouse

Employment $0 SNA $0 SNA
Self-employment $0 SNA $o SNA
Income from real property $0 $NA $o $NA
(such as rental income)
Interests and dividends go $ NIA go 3 NA
Gifts $0 $_NA So SNA
Alimony $0 $NA $o S$ N/A
Child support $o $NA $0 $ NIA
Retirement (such as Social Security, pensions, annuities, $0 3 WA $o SNA
insurance)
Disability (such as Social Security, insurance payments) 30 S_WA $0 SNA
Unemployment payments $0 $_N/A $o $NA
Public-assistance (such as welfare) $0 SNA = $0 $NA
Other (specify): Loan $ 3260 $NA $ 3260 $ NA

Total monthly income: $ 3260 S$ N/A $ 3260 $NA

(Rev. 12/98)



2. List your employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.)

Employer Address Dates of Employment Gross Monthly Pay
UF, Levin College of Law Gainesville, Florida 32611 7/01/2001-12/31/2007 @ 8,000

3. List your spouse’s employment history, most recent employer first. (Gross monthly pay is before taxes or other
deductions.)
N/A

4. How much cash do you and your spouse have? $100

Below, state any money you or your spouse have in bank accounts or in any other financial institution.

Financial Institution Type of Account Amount you have Amount your spouse has
TIAA-CREF. Retirement Annuity $$53,343.19 $
$ $

$ $

If you are a prisoner seeking to appeal a judgment in a civil action or proceeding, you must attach'a statement
certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six
months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple
institutions, attach one certified statement of each account.

5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household
Surnishings.

Home (Value) Other Real Estate (Value) Motor Vehicle #1 (Value)
160,000 NWA Make & Year: 2002 Landrover

Model: Freelander

Registration #: N/A

Other Assets(Value) Other Assets (Value) Motor Vehicle #2 (Value)
NA N/A Make & Year:

Model:

Registration #:

6. State every person, business, or organization owing you or your spouse money, and the amount owed.

Person owing you or your
spouse money Amount owed to you Amount owed to your spouse

N/A



7. State the persons who rely on your or your spouse for support.
Name Relationship

N/A

8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse.
Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate.

You Your Spouse
For home-mortgage payment (include lot rented for mobile home) $ 1860.00 $NA
Are real-estate taxes included? J Yes C1 No SNA $NA
Is property insurance included? [I Yes [No SNA $NA
Utilities (electricity, heating fuel, water, sewer, and telephone) $ 637.00 $NA
Home maintenance (repairs and upkeep) $ N/A $ N/A
Food. $ 400.00 3 NA
Clothing $NA $ N/A
Laundry and dry-cleaning $ WA _ $ N/A
Medical and dental expenses $NA $ N/A
Transportation (not including motor vehicle payments) $ 200.00 $ N/A
Recreation, entertainment, newspapers, magazines, etc. $NA : $NA
Insurance (not deducted from wages or included in mortgage payments) $_WA SNA
Homeowner’s or renter’s $ N/A $NA
Life $NA $ NA
Health $_N/A $NA
Motor Vehicle $ 160.00 $NA
Other: $NA $ NWA
Taxes (not deducted from wages or included in
mortgage payments) (specify): $_N/A $ N/A
Installment payments $NA $ N/A
Motor Vehicle $NA $ N/A
Credit card (name): $ N/A $NA
Department store (name): $NA SNA
Other: $ N/A $ NA
Alimony, maintenance, and support paid to others $ N/A 3 N/A
Regular expenses for operation of business, profession, or farm (attach detailed $ N/A $ N/A
statement)
Other (specify): $ N/A $NA
Total monthly expenses $ 3257.00 $ N/A