Declaration In Support Of Request To Proceed In Forma Pauperis {3C-P-373}

IN THE CIRCUIT COURT OF THE THIRD CIRCUIT STATE OF HAWAI324I ) PLAINTIFF(S) ) ) ) ) ) ) ) ) ) ) VS DEFENDANT(S) ) ) 002 003 002 Reprographics (03/07) DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS 3C-P-373 NO. DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS I,, am the Plaintiff in the above-entitled case. In support of my motion to proceed without being required to prepay fees or costs or give security therefor, (knowing fully that this does not cover the request or cost for transcripts, service fees, etc.), I state that because of my poverty, I am unable to pay the costs of said proceedings or give security therefor; that I believe I am entitled to redress. I declare that the responses which I have made below are true. 1.255 Are you presently employed? Yes No a)255 If the answer is yes, state the amount of your salary per month and give the name and address of your employer. b)255 If the answer is no, state the date of last employment and the amount of the salary per month which you received. In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at the Circuit Court Administration Office at PHONE NO. 961-7440, FAX 961-7416, or TTY 961-7525 at least ten (10) working days prior to your hearing or appointment date. American LegalNet, Inc. www.FormsWorkFlow.com 2. Have you received within the past twelve months any money from any of the following sources? a) Business, professional or form of self-employment? Yes Nob) Rent payment, interest or dividends? Yes Noc) Pension, annuities or life insurance payment? Yes 002 002 002 No 002 002 002 002 d) Gifts or inheritances? 002 Yes 002 No e) Any other sources? 002 Yes No 002 002 Reprographics DECLARATION IN SUPPORT OF REQUEST TO (03/07) PROCEED IN FORMA PAUPERIS 3C-P-373 If the answer to any of the above is yes, describe each source of money and state the amount received from each during the past twelve months. 3. Do you have any cash or do you have money in a checking or savings account? (Including any funds in prison accounts.) Yes No 002 If the answer is yes, state the total value owned: 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishing and clothing)? Yes No 002 If the answer is yes, describe the property and state its approximate value: 5. List the persons who are dependent upon you for support; state your relationship to those persons; and indicate how much you contribute toward their support American LegalNet, Inc. www.FormsWorkFlow.com I UNDERSTAND THAT A FALSE STATEMENT OR ANSWER TO ANY QUESTION IN THIS DEC255LARATION WILL SUBJECT ME TO PENALTIES FOR PERJURY. Plaintiff325s Signature Reprographics DECLARATION IN SUPPORT OF REQUEST TO (03/07) PROCEED IN FORMA PAUPERIS 3C-P-373 I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signed this day of, 20Plaintiff325s Signature APPROVED AND SO ORDERED: Judge of the above-entitled Court American LegalNet, Inc. www.FormsWorkFlow.com