D.C. Court of Appeals
D.C. Dept. Human Rights
MOTION AND AFFIDAVIT TO PROCEED ON APPEAL
IN FORMA PAUPERIS
I, Gary Freedman, being first duly sworn, depose and say that I am the appellant or petitioner in the above-entitled case and that I seek authorization to proceed on appeal without being required to prepay fees, costs or give security therefor. In support of my motion, I state that because of my poverty I am unable to pay the costs of said proceeding or give security therefor. I believe I am entitled to relief. The issues that I want to present on appeal are the following: appeal of agency no probable cause determination - no substantial evidence in record for determination, not in accordance with law.
I further swear that the responses which I give to the questions and instructions below relating to my ability to pay the costs of prosecuting the appeal are true.
1. Are you presently employed? Yes _____ No _X____
a. If the answer is yes, state the amount of your salary or wages per month and give the name and address of your employer.
b. If the answer is no, state the date of your last employment and the amount of the salary and wages per month which you received. Oct. 29, 1991/$2500 per mo. $30,000 per years
2. Have you received within the past twelve months any income from a business, profession or other form of self-employment, or in the form of rent payments, interest, dividends, or other source?
Yes _X____ No _____
a. If the answer is yes, describe each source of income, and state the amount received from each during the past twelve months.
(1) unemplyment compensation, about $1172;
(2) social security disability, $1262
3. Do you own any cash or checking or savings accounts?
Yes _X____ No _____
a. If the answer is yes, state the total value of the items owned.
4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)?
Yes _____ No _X____
a. If the answer is yes, describe the property and state its approximate value.
5. List the persons who are dependent upon you for support and state your relationship to those persons.
I understand that a false statement or answer to any of the questions in this affidavit will subject me to penalties for perjury.
Signature of Applicant:
3801 Connecticut Ave NW
Apt. 136/Wash. DC 20008-4530
Wash DC 20008-4530
(202) 362-7064 or (202) 363-3800
SUBSCRIBED AND SWORN TO before me this __________ day of __________ 19_____.
Notary Public or other Officer
authorized to administer oath
NOTE: YOU MUST ANSWER ALL OF THE QUESTIONS. FAILURE TO ANSWER ALL QUESTIONS COMPLETELY WILL RESULT IN THE DENIAL OF YOUR MOTION
[Stamp: District of Columbia Court of Appeals REC'D OCT 22 1993]