I, ________________________________ declare that I am the owner of the property in the above-entitled case; that in support of my motion to proceed without being required to post a monetary bond or give security therefor, I state that because of my poverty I am unable to pay the costs of this proceeding or to give security therefor; that I believe that I am entitled to relief; that the answers I give to the following questions are true.

1.   Are you employed? Yes ( ) No ( )

If the answer is "yes," state the amount of wages you receive per month. $ ______________

Give the name and address of your employer.

Name ____________________________
Address _____________________________________
_____________________________________
 

If the answer is "no," state the date when you were last employed, and the amount of wages you received per month.

Date ________________________ Amount $ ______________

2.    Have you received any money from any of the following sources during the past twelve months?

Business, profession or self-employment? Yes ( ) No ( )

Rent payment, interest or divident? Yes ( ) No ( )

Pension, annuity or life insurance payment? Yes ( ) No ( )

Gift or inheritance? Yes ( ) No ( )

If the answer is "yes," describe each source of money. State the amount received during the past twelve months.
 

Source                                                                             Amount
 

__________________________                     ___________________________
__________________________                     __________________________

3.  Do you have money in any of the following forms?

Cash? Yes ( ) No ( )

Savings account? Yes ( ) No ( )

Checking account? Yes ( ) No ( )

Prison account? Yes ( ) No ( )

If the answer is "yes," state the total amount of money in each account.

Account                                                                             Amount
__________________________                                 ___________________________
__________________________                                 ___________________________
__________________________                                 ___________________________
 

4.  Do you own any real estate, stocks, bonds, notes, automobiles or other valuable property? Yes ( ) No ( )

If the answer is "yes," describe the property and state its approximate value. (Do not report ordinary household furnishings or clothing.)
 

Property                                                                                         Value
__________________________                                     ___________________________
__________________________                                     ___________________________
__________________________                                     ___________________________
 

* Are any persons dependent upon you for support?

Yes ( ) No ( )

If the answer is "yes," list the persons who are dependent upon you for support. State your relationship to each person. Indicate how much you contribute to his/her support.
 

Name                                                     Relationship                                                 Amount

_________________________         _____________________                     $____________

_________________________         _____________________                     $____________

_________________________         _____________________                     $____________
 

I declare under penalty of perjury that the foregoing is true and correct.

____________________                                                                 _____________________________
Date                                                                                                                 Signature