Petition To Proceed In Forma Pauperis Page 6
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114. I have the following average monthly expenses for the indicated items:
Housing:
Insurance:
Utilities:
Transportation:
(Gas):
Medical:
(Oil):
Loans:
(Electric):
Laundry:
(Phone):
Child Care:
Food:
Child Support:
Clothing:
5. I neither own nor have equity in any assets other than the following (state values in dollars):
.
6. I am unable to pay the costs of these proceedings or to obtain the amount of costs from family or friends.
WHEREFORE, Petitioner prays that he/she be permitted to proceed in this matter in forma pauperis.
Petitioner
(Print your name)
Date:
Petitioner
(Sign your name)
Page 3 of 8
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