ilf you need additional space for ANY section, please attach an additional sheet and reference that section.l

UNITED STATES DISTRICT COURT FOR THE

NORTHERN DISTRICT OF ILLINOIS

Plaintiff

Monthly amount:

2. Are you currently employed?

A. If the answer is o'yes,"state your:

Monthly salary or wages.'

Name and address of employer:

v.&"nat DIir\lon,, Ohatr un'rfsd

Stat<.s Egua I Eivrpbrt vit^f

O?fort nn*Jq Co*ilnttt,r^ .

Do you receive any payment from

rD #: No+ ftFf liCAbE- Name orprison or jail: N of nff t;f-a-bt<-

theinstitution? ffi

If the answer is"no," state your:

Beginning and ending dates of la.st employment: Of (at [?.,0 tl - Oq I f ( | eO l9

Last monthly salary or wages: S t,0 t 5.

Instructions: Please answer every question. Do not leave any blanks. If the answer is o'none" or

"not applicable (N/A)," write that response. Wherever a box is included, place a / inwhichever

box applies. If you need more space to answer a question or to explain your answer, attach an

additional page that refers to each such question by number and provide the additional

information. Please print or type your answers.

Application , t,(liZA,bgth Clo nZq\eZ , declare that I am tne dptaintiff

E petitioner E movant E (oth". Not A?PliCab [€- 

-) 

in the

above-entit1edcase.Thisaffidavitconstitutesmyuppli.utio,,@outfull

prepayment of fees, or E in support of my motion for appointment of counsel, or E both. t

declare that I am unable to pay the costs of these proceedings, and I believe that I am entitled to

the relief sought in the complaint/petition/motion/appeal. In support of my application, I answet

the following questions under penalty of perjury.

1. Are you currently incarcerated? E Yes MNo

(If "No" go to question 2.)

IN FORMA PAUPERIS APPLICATION

AND FINANCIAL AFFIDAVIT

Case Number:

Judge:

D Yes dNo

l<-

B.

and address of employer:

3. Are you married?

If the answer is "yes", is your spouse currently employed?

No

No

tr

tr

Yes

Yes

[lf you need additional space for ANY section, please attach an additional sheet and reference that section.]

Rev. 06/03i201 6

tr

FILED 3/31/2020

THOMAS G. BRUTON CLERK, U.S. DISTRICT COURT

20CV2111

Case: 1:20-cv-02111 Document #: 4 Filed: 03/31/20 Page 1 of 4 PageID #:107
4.

[lf you need additional space for ANY section, please attach an additional sheet and reference that section.]

Spouse's Monthly salary or wages.' wName and address of employer:

In addition to your income stated above in response to Question 2 (which you should not

repeat here), have you or anyone else living at the same residence received more than

$200 in the past twelve months from any of the following sources? Place a y' next to

"Yes" or "No" in each of the categories A through G , check all boxes that apply in each

category, and fill in the twelve-month total in each category.

A. tr Salary or E Yes dNo

Total received

Received by:

E wages

in the last 12 months:

B.

C.

D.

El Business, E

Total received in

E Rental income, EI

Total received in the

profession or fl other self-employment

the last 12 months:

interest or E dividends

last l2 months:

E Yes dNo

E Yes JNo

E Yes dNo

d v.. EI No

E Yes JNo

Received by:

Received by:

EI Pensions, D social security, El annuities, E life

insurance, tr disability, E workers' compensation,

E alimony or maintenance or tr child support

Total received in the last 12 months:

Received by:

E. d cirrr or E inheritances

Total received in the last l2 months:

Received by:

F. E Unemployment, E welfare, or E any other public

assistance

Total received

Received by:

in the last 12 months:

5.

G. tr Any other sources (describe source: ) EI Yes

Total received in the last l2 months:

Received by:

Do you or anyone else living at the same residence have more E Yes

than $200 in cash or checking or savings accounts?

Total amount:

In whose name held: Relationship to you:

[lf you need additional space for ANY section, please attach an additional sheet and reference that section.]

Rev. 06/03/20 I 6

d*o

dNo

Case: 1:20-cv-02111 Document #: 4 Filed: 03/31/20 Page 2 of 4 PageID #:108
[lf you need additional space for ANY section, please attach an additional sheet and reference that section.]

6.

7.

Do you or anyone else living at the same residence own any

stocks, bonds, securities or other financial instruments?

Current value:

E Yes

Property:

ln whose name held: Relationship to you:

Do you or anyone else living at

mortgage)? Real estate includes

cooperative, two-fl at, etc.

the same residence own any real estate (with or without a

, among other things, a house, apartment, condominigm,

E Yes dNo

Type ofproperty and address:

Current value: Equity: (Equity

it.) is the difference between what the property

In whose name held:

is worth and the amount you owe on

Relationship to you:

Amount of monthly mortgage or loan payments:

Name of person making payments:

8. Do you or anyone else living at the same residence own any automobiles with a current

market value of more than $1000 ? E Yes d No

Year, make and model:

Current value: Equity: (Equity is

the difference between what the automobile is worth and the amount you owe on it.)

Amount of monthly loan payments:

In whose name held: Relationship to you:

Name of person making payments:

g. Do you or anyone else living at the same residence own any boats, trailers, mobile homes

or other items of personal property with a current market value of more than S I 000?

E Yes dNo

Property:

Current value: Equity: (Equity

it.) is the difference between what the property is worth and the amount you owe on

Amount of monthly loan payments:

In whose name held: Relationship to you:

Name of person making payments:

10. List the persons who live with you who are dependent on you for support. State your

relationship to each person and state whether you are entirely responsible for the person's

support or the-specific monthly amount you contribute to his or her support. If none,

check h.r.' dNon..

I l.

[lf you need additional space for ANY section, please attach an additional sheet and reference that section.]

Rev.06/03/2016

List the persons who do not live with you

your relationship to each persog and state

support. Ifnone, check here: M None.

who are dependent on you for support. State

how much you contribute monthly to his or her

Case: 1:20-cv-02111 Document #: 4 Filed: 03/31/20 Page 3 of 4 PageID #:109
[lf you need additional space for ANY section, please attach an additional sheet and reference that section.]

I declare under penalty of perjury that the above information is true and correct. I understand

that 28 U.S.C. $ l9l5(eX2)(A) states that the court shall dismiss this case at any time if the

court determines that my allegation of poverty is untrue.

out",7ZlN l9-0),C

NOTICE TO PRISONERS: In addition to the Certificate below" a prisoner must also attach a

institution(s) where he o rins the last six

showinq all receipts. expenditures and balances in the prisoner's prison or jail trust fund

accounts during that period. Because the law requires information as to such accounts covering

a full six months before you have filed your lawsuit, you must attach a sheet covering

transactions in your own account - prepared by each institution where you have been in custody

during that six-month period. As already stated, you must also have the Certificate below

comoleted bv an authorized officer at each institution.

CERTIFICATE

(Incarcerated applicants only)

(To be completed by the institution of incarceration)

I certifu that the applicant named herein, ,\.D.# , has

the sum of $ on account to his/her credit at (name of institution)

I further certifu that the applicant has the following

securities to his/her credit: I further certiff that during the past six months the

applicant's average monthly deposit was $ (Add all deposits from all

sources and then divide by number of months).

Date Signature of Authorized Officer

(Print Name)

[lf you need additional space for ANY section, please attach an additional sheet and reference that section.]

Rev.06/03/2016

Case: 1:20-cv-02111 Document #: 4 Filed: 03/31/20 Page 4 of 4 PageID #:110