WPC r˚Q`OښDEv',.ݚf"$e_fQ;a"mPo8{нvɫf/ӿzp(3eY+ G{mTmϰvNE+F&HxίuN }]KlN\d,asH 7crjP! , 5JqHtF0/tC!2:b.?4de-w#smK NJ fr}C2$gr2IzNG$I.2ؽZ`K{Cæ ~ets#|[8Ƈcbe8uB e$@)pz{gRȪ起߄qXs\{U81x>'k$ļ5_ڹOlyREƴ셵gi# % f 0( U!N a ^  w 4! 5 D mF ] #   u ;NYn[f 0D  0DNae Nfa Bq B* BB B-FFFFFFFFFF B*s\\DMN_TREE\md-is4050_q,,,,0X($(hH  Z6Times New Roman RegularTABLE ADi2s ~2x}&Suite83|xULevel 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5 AO USM* `(CG TimesScalableXXw P7XP(3$ !  (3$ !  TABLE B   k   )  _,,XX&X.C:\Documents and Settings\wegner\My Documents\IFP appl - AO240.WPDC:\DocumentsandSettings\wegner\MyDocuments\IFPappl-AO240.WPD/  @  %Page  1  ڀof  3  ڈ>">";&FormModified06/06/05pTABLE A d&p Pd d>Thin/Thick 2[ -d d)Hairline d&0 d d !  _,p( *Vddd Xdd Xdd X%%,4$$ ,J$$ ,$$ ,f$$ ,$$ ,$$ ,$$ ,e$$ ,$$ ,2$$ ,{$$ ,$$ ,$$ ,$$ ,K$$ ,$$ ,,$$ ,$$ ,$$ ,e$$ ,$$ ,[$$ +  8. 8XX.AO240(Rev.10/03)DCMODIFIED _hN/   H_ Gh6$~h G Gh6$~h G XN/~ H h X  F^> UnitedStatesDistrictCourt  [VJ/    [X"XF^  @V/! V @ @V/!V @ @V/!V @ @V/! V @ =3! V  =  y XX"DistrictofMinnesota#X"X yj# CV2$    C @V/! V @ @V/! V @ @V/!V @ @V/!V @ UK,  V tU ZVI/ t  Z QG5Oo"V Q  ND*c  N 7-Oo 7 @6$Oo  @ ~ XX"APPLICATIONTOPROCEED#X"X ~ # SI*Oo   S  Plaintiff @6$Mm  @ QG5Mm00  Q ~ XX"WITHOUTPREPAYMENTOF#X"X ~3 # XN/Mm    X  V.XX" QG5K k vv Q 7-K k 7 #X"X #~ XX"FEESANDAFFIDAVIT#X"X ~ # XN/K k    hX 7-N n 7 7-N n 7 kVZ@N nvv h   k  QG5   V Q 7-  7 E;!   E 7-  7 7-  7XX"CASENUMBER:#X"X# GV6$  G SI*  V S  Defendant @6$ !  @ XN/ "   X TJ/z #   T&7r%XX"I, DV3!f $  D  @6$f % V   @declarethatIamthe(checkappropriatebox) TJ/f &    dT =3!>^' = ZVVVVG/>^( d  Z =3!)VVVV =petitioner/plaintiff/_movant_ BVVVV/$* B =3!+VVVV =other XN/,   tX XN/z- t  Xintheaboveentitledproceeding;thatinsupportofmyrequesttoproceedwithoutprepaymentoffeesorcosts SI/.   S  under28_USC_Ԁ1915IdeclarethatIamunabletopaythecostsoftheseproceedingsandthatIamentitledtothereliefsought / inthecomplaint/petition/motion. SI*0  xS XN/v1 x  XInsupportofthisapplication,Ianswerthefollowingquestionsunderpenaltyofperjury: XN/2   xX wm/3 x   ?1?w1. ^TB>^4  ?1 ? ^Areyoucurrentlyincarcerated? FVVVV3$>^5 F @6$>^6"VVVV @Yes FVVVV3$>^7 F @6$>^8"VVVV @No @6$>^9 @(If No,gotoPart2) XN/>^:   tX XN/6; t  X @6$< @If Yes,statetheplaceofyourincarceration GV6$=  G XN/>  V  tX XN/b? t  X @6$@ @Areyouemployedattheinstitution? GV6$A G  @6$B V  @ЀDoyoureceiveanypaymentfromtheinstitution? CV2$C  C  UK,D   V tU XN/E t  X @6$"BF @  Attachaledgersheetfromtheinstitution(s)ofyourincarcerationshowingatleastthepast six months XN/"BG   X @6$H @transactions. XN/I   xX xn/J x   @2.@x2. _UCNnK  @2. @ _Areyoucurrentlyemployed? FVVVV3$NnL F @6$NnM"VVVV @Yes FVVVV3$NnN F @6$NnO"VVVV @No XN/NnP   tX SI/&FQ t  S @6$R @a. @6$S @  Iftheansweris Yes,statetheamountofyourtakehomesalaryorwagesandpayperiodandgivethenameand T addressofyouremployer. SI*rU  S 7-$JjV 7 J@&JjW   J @6$#!CX @b. @6$#!CY @  Iftheansweris No,statethedateofyourlastemployment,theamountofyourtakehomesalaryorwagesandpay #!CZ periodandthenameandaddressofyourlastemployer. SI*! [  S 7-$" \ 7 oe&" ]    @3.@o3. _UC$"^  @3. @ _Inthepast12twelvemonthshaveyoureceivedanymoneyfromanyofthefollowingsources? XN/$"_   tX XN/%#` t  X @6$&0$a @a. @6$&0$b  @Business,professionorotherselfemployment FVVVV3$&0$c  F @6$&0$d"VVVV @Yes FVVVV3$&0$e F @6$&0$f"VVVV @No XN/&0$g   X @6$&%h @b. @6$&%i  @Rentpayments,interestordividends FVVVV3$&%j  F @6$&%k"VVVV @Yes FVVVV3$&%l F @6$&%m"VVVV @No XN/&%n   X @6$'%o @c. @6$'%p  @Pensions,annuitiesorlifeinsurancepayments FVVVV3$'%q  F @6$'%r"VVVV @Yes FVVVV3$'%s F @6$'%t"VVVV @No XN/'%u   X @6$(&v @d. @6$(&w  @Disabilityorworkerscompensationpayments FVVVV3$(&x  F @6$(&y"VVVV @Yes FVVVV3$(&z F @6$(&{"VVVV @No XN/(&|   X @6$p)'} @e. @6$p)'~  @Giftsorinheritances FVVVV3$p)'  F @6$p)'"VVVV @Yes FVVVV3$p)' F @6$p)'"VVVV @No XN/p)'   X @6$H*h( @f. @6$H*h(  @Anyothersources FVVVV3$H*h(  F @6$H*h("VVVV @Yes FVVVV3$H*h( F @6$H*h("VVVV @No SI/H*h(   S @6$ +@) @ ND* +@)  N @6$+* @  Iftheanswertoanyoftheaboveis Yes,describe,initem7onthefollowingpage,eachsourceofmoneyandstatethe +* amountreceivedandwhatyouexpectyouwillcontinuetoreceive. SI*,*  S @6$-+ @ wm/-+    @4@w4. ^TB.,  @4 @  ^Doyouhave any cashorcheckingorsavingsaccounts? FVVVV3$.,  F @6$.,VVVV @Yes FVVVV3$., F @6$.,VVVV @No XN/.,   X @6$\/|- @If Yes,statethetotalamount(s). GV6$\/|- G ?53\/|-  2 V ?p( k    _*Vd3d4$$ 4J$$ J$$ f$$ f$$ $$ $$ e$$ e$$ 2$$ 2{$$ {$$ $$ $$ K$$ K$$ ,$$ ,$$ $$ e$$ e$$ [$$ [V%%,$$ ,$$ ,$$ ,$$ ,$$ ,$$ ,$$ ,$$ ,$$ ,$$ +  8.  8 %&7rԀAO240Reverse(Rev.10/03)DCMODIFIED&7r% _hN/    H_ Gh6$~h G XN/~ H h xX @6$ @ si/ x   @5.@s5. _UC>^  @5. @ _Doyouownanyrealestate,stocks,bonds,securities,otherfinancialinstruments,automobilesoranyother SI*>^  S @6$6 @thingofvalue? BVVVV/$6  B =3!6 VVVV =Yes BVVVV/$6  B 9/!6 VVVV 9No UK,6    U @6$ @ XN/   X @6$ @If Yes,describethepropertyandstateitsvalue. XN/   X 7-$ 7 OE&   O @6$& F  @ si/& F     @6.@s6. _UC    @6. @ _Listthepersonswhoaredependentonyouforsupport,stateyourrelationshiptoeachpersonandindicatehowmuch    youcontributetotheirsupport.ListMinorChildrenbelowbyinitialsonlyandcompleteattachedReferenceListfor   thoseMinors. SI*   S 7-$  7 oe&     @7.@o7. _UC.  @7. @ _Additionalinformation(includesourcedescriptionsfromitem3): XN/.   PX 7-$ 7 OE& P  O @6$6V  @ TJ/6V!   TI, DV3!." D @6$.#V @declare,underpenaltyofperjury,thattheaboveinformationistrueandcorrect. XN/.$    X _VN/%    _  <2$& V < DV3!' D XN/(  V X  Ҕ%&7rDate <2$)  < =3!* =  SignatureofApplicant?53+     ? X"XҔ@66%CERTIFICATE  -  #ҔXX"N#&7r%Ҕ@GG( Incarceratedapplicantsonly ) !. @\ \ (Tobecompletedbytheinstitutionofincarceration) " / I,___________________________,certifythattheapplicantnamedhereinhasthesumof$_________________onaccount 9$Y"1 tohis/hercreditat(nameofinstitution)_________________________________________.Ifurthercertifythatthe %1#2 applicanthasthefollowingsecuritiestohis/hercredit:______________________________________________ % $3 _________________________________________________________________________________________. &$4 Ifurthercertifythatinthe6monthperiodimmediatelyprecedingthefilingofthecomplaint/petition/motionornoticeof q(&6 appeal,theaveragemonthlydepositstotheprisonersaccountwas$____________________,andtheaveragemonthly I)i'7 balanceintheprisonersaccountwas$_____________________. !*A(8 _______________________________________________________________________________________ +): ЀDATE   @    SIGNATUREOFAUTHORIZEDOFFICER#Ҕ%&7rmO#  ,*; X@   ҔUNITEDSTATESDISTRICTCOURT#Ҕ T#X"XҔԈ X @   #ҔXX"UU#y ҔDISTRICTOFMINNESOTA#Ҕ yU#X"XҔ  : @*   `     h      p REFERENCELIST j    `     h      p FILEDUNDERSEAL V _______________________________ .     `    Plaintiff,    vs.   `     h     CivilActionNumber____cv________/____   ________________________________   ________________________________ r  ________________________________ ^  ________________________________ J    `    Defendant(s) 6 Є z" 0  0` (#(#0 ` (#` (#  (# (# *Vd d$$ $$ $$ $$ $$ $$ $$ $$ $$ $$ V(#(#,<dd ,<dd +  $ $MINORCHILDRENSINITIALS 'z"" 'MINORCHILDRENSNAME 'z"" ' '" ' '" ' 'z"" ' 'z"" ' '" ' '" ' 'z"" ' 'z" " ' '!" ' '"" ' 'z "#" '"z "$"  "DATED:______________0  0h(#(#  F%"(h(#h(#    `     h   SignatureofPlaintiff#ҔXX"V#