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                              MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS


        I, .          .-zlaze.
                          'I         Pr6J~f-. f-tfZ> I s-rrt               do hereby request leave to
proceed in forma pauperis ~d state unaer oath that I am unable to pay the costs for commencement of this
_ _ _ _ _ _ _ _ _ action, or to give security therefor, and that I believe I am entitled to redress.

         I further state the   foll<?w~ng:     ·/

                       I am not employed (   i~·
                       Imnemployedh;:        ~ ~~(e/ Jkrr0-{;pWiJfb-,//
                       and my salary is $ _ _ _ _ _ _ _ _ _ _ per---'---~-----·

          I have no other sources of income except the following (include public assistance, social security
disability, or any other income not included above employment and state the amount):




         I have $_ _ _ _ _        (§
                                  ___,. _,______         IN CASH.

         I have the following funds in the bank:


 NAME OF THE BANK                            TYPE OF ACCOUNT                    AMOUNT

   - J //}I j_f ,..---                                                          $           \'?\
      .,-_ .......   /'""'
                                                                                $
                                                                                            ~
                                                                                $


        I own the following valuable property (include real estate, stocks, bonds, notes, automobiles, and other
valuable property, but exclude ordinary household furnishings and clothing):


                                                                                VALUE

                                                                                $

                                                                                $

                                                                                $


        I have the following debts:
