Motion to Proceed In Forma Pauperis — John Anthony Arnold, Petitioner v. Virginia

“ “S

IN THE

SUPREME COURT OF THE UNITED STATES

Jokti Arnold Il08h$8

— PETITIONER

(Your Name)

VS.

Si trrf/tf. fourfdP t/iiVMfi— RESPONDENT(S)

MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

The petitioner asks leave to file the attached petition for a writ of certiorari

without prepayment of costs and to proceed in forma pauperis.

[ ] Petitioner has previously been granted leave to proceed in forma pauperis

in the following court(s):

[ ^Petitioner has not previously been granted leave to proceed in forma

pauperis in any other court.

Petitioner’s affidavit or declaration in support of this motion is attached hereto.

AFFIDAVIT OR DECLARATION

IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

Tl ll/)f)

tftbl'jfy. am the petitioner in the above-entitled case. In support of

my motion to proceed in forma pauperis, I state that because of my poverty I am unable to pay

the costs of this case or to give security therefor; and I believe I am entitled to redress.

1. For both you and your spouse estimate the average amount of money received from each of

the following sources during the past 12 months. Adjust any amount that was received

weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross

amounts, that is, amounts before any deductions for taxes or otherwise.

Income source

Average monthly amount during

the past 12 months

Spouse

You

Employment

Self-employment

Income from real property

(such as rental income)

UA

$ UA

$ AM

$. MA

slx i;a

*1* m

i

You

$.

Aja

$.

MA

$_m //

a

$.

Spouse

MA

a MA h

$.

$.

$.

$.

$.

$.

$.

Alimony

$.

$.

$.

$.

Child Support

$.

$.

$.

$.

Retirement (such as social

security, pensions,

annuities, insurance)

$.

$.

$.

$.

$.

Disability (such as social

security, insurance payments)

$.

$.

$.

Unemployment payments

$.

$.

$.

$.

Public-assistance

(such as welfare)

$.

$.

$.

$.

Other (specify):

$.

$.

$.

$.

$.

$.

$.

$.

Interest and dividends

$.

Gifts

Total monthly income:

b

$.

Amount expected

next month

_

Is

2. List your employment history for the past two years, most recent first. (Gross monthly pay

is before taxes or other deductions.)

Employer

Address

j/irfm Dtd~

UlM

Gross monthly pay

Dates of

f ‘m‘

$

$

Tafirfaemr.

SU.OO___

/;;.qq

$

3. List your spouse’s employment history for the past two years, most recent employer first.

(Gross monthly pay is before taxes or other deductions.)

Employer

Address

ma

air

Gross monthly pay

Dates of

Employment

S A)A

$.

$.

L/

4. How much cash do you and your spouse have? $------------------------------.---- .---Below, state any money you or your spouse have in bank accounts or in any other financial

institution.

Financial institution

hP\

Type of account

m

Amount you have

Amount your spouse has

$

$.

$.

$.

$ pn

$_AlR

U

iih5. List the assets, and their values, which you own or your spouse owns. Do not list clothing

and ordinary household furnishings.

□ Home

Value

□ Motor Vehicle #1

Year, make & model

Value_____ ______

□ Other assets

Description _

Value_____

4

□ Other real estate

Value_________

□ Motor Vehicle #2

Year,

make & model

/

Value___________

*

V

6. State every person, business, or organization owing you or your spouse money, and the

amount owed.

Person owing you or

your spouse money

AjA

Amount owed to you

Amount owed to your spouse

$.

$.

$.

$.

$.

$.

7. State the persons who rely on you or your spouse for support.

Name

Age

Relationship

M

8. Estimate the average monthly expenses of you and your family. Show separately the amounts

fjfa paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, or

annually to show the monthly rate.

You

Your spouse

uh

Rent or home-mortgage payment

(include lot rented for mobile home)

Are real estate taxes included? □ Yes □ No

Is property insurance included? □ Yes □ No

Utilities (electricity, heating fuel,

water, sewer, and telephone)

/UA

Home maintenance (repairs and upkeep)

$.

$.

Food

Clothing

$.

Laundry and dry-cleaning

$.

Medical and dental expenses

$.

$_

You

Your spouse

Transportation (not including motor vehicle payments)

$.

$.

Recreation, entertainment, newspapers, magazines, etc.

\\

$.

h

m

$.

Insurance (not deducted from wages or included in mortgage payments)

Homeowner’s or renter’s

$.

$.

Life

$.

$.

Health

$.

Motor Vehicle

$.

Other:

$.

$.

Taxes (not deducted from wages or included in mortgage payments)

(specify):

$.

Installment payments

Motor Vehicle

Credit card(s)

$.

$.

$.

Department store(s)

$.

Other:

$___ _

Alimony, maintenance, and support paid to others

$.

Regular expenses for operation of business, profession,

or farm (attach detailed statement)

$.

$.

Other (specify):

$.

$.

Total monthly expenses:

$.

$.

t

V. f

9. Do you expect any major changes to your monthly income or expenses or in your assets or

liabilities during the next 12 months?

□ Yes

£fNo

If yes, describe on an attached sheet.

10. Have you paid - or will you be paying - an attorney any money forjprviices in connection

with this case, including the completion of this form? □ Yes SZNo

If yes, how much?________________ _____

If yes, state the attorney’s name, address, and telephone number;

11. Have you paid—or will you be paying—anyone other than an attorney (such as a paralegal or

a typist) any money for services in connection with this case, including the completion of this

form?

□ Yes

If yes, how much?

If yes, state the person’s name, address, and telephone number:

12. Provide any other information that will help explain why you cannot pay the costs of this case

X ah a Prisoner in ihf 1/immCi bept oP Corrcdr^ns

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

Executed on:

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* s

Virginia Department of Corrections

Offender Pay Statement

Facility:

BASKERVILLE CORRECTIONAL CENTER FG

Pay Period :

06/03/2019 -07/07/2019

06/09/2019 05-Housekeeping

1-Hskp AM skilled

Comments

pi nth n F iijtil. r Adjiistnn n' Net

Pay

Pay Hrs Pay

Pay

IPBACCC_A0603201907072019

HU1-B-33-B

13.50

0.00

13.50

0.45 s 30

06/16/2019 05-Housekeeping

1-Hskp AM skilled

0.45

130

13.50

0.00

06/23/2019 05-Housekeeping

1-Hskp AM skilled

0.45

|30

13.50

0.00

1-Hskp AM skilled

0.45

*30

13.50

0.00

13.50

130

13.50

0.00;

13.50

i 150

67.50

0.00

67.50

Week

Ending

1108658

Pa\

Rate

Job Name

ICC

Arnold, John Anthony

06/30/2019 05-Housekeeping

07/07/2019 05-Housekeeping

1-Hskp AM skilled

Total

HU1-B-33-B

1108658

0.45.

Arnold, John Anthony

13.50

.

13.50

.. Printed on 9/11/2019 2:29:29 PM:

i

k

* Vj

Virginia Department of Corrections

Offender Pay Statement

Facility:

BASKERVILLE CORRECTIONAL CENTER FG

Pay Period :

05/06/2019-06/02/2019

ICC

1108658

[Arnold, John Anthony

05/26/2019 05-Housekeeping

06/02/2019 05-Housekeeping

Pay

Rate

W f JlUIUt-'Mi

Regular Regular Adjustment Net

Pay

PayHrs Pay

Pay

IPBACCC_A0506201906022019

:HU1-B-33-B

Job Name

Week

Ending

1-Hskp AM skilled

1-Hskp AM skilled

Total

HU1-B-33-B

1108658

~^0^45~"”l30

s

0.45

130

" 13.50

0.00

13.50

o.oo

i

1i3~50

i60

27.00

0.00

27.00

Arnold, John Anthony

13.50

Printed on 9/11/2019 2:28:43 PM

■;

■k.'s'

Virginia Department of Corrections

Offender Pay Statement

Facility:

BASKERVILLE CORRECTIONAL CENTER FG

Pay Period :

07/08/2019-08/04/2019

Comments

Regular Regular Adjustment Net

Pay

PayHrs Pay

Pay

IPBACCC_A0708201908042019

HU1-B-33-B

Job Name

Pay

Rate

"07/14/2019 05-Housekeeping

1-Hskp AM skilled

jO.45

30

13.50

[0.00

13.50 1

07/21/2019 05-Housekeeping

1-Hskp AM skilled

j0.45

30

13.50

|0.00

13.50

07/28/2019 05-Housekeeping

1-Hskp AM skilled

10.45

30

13.50 .

[0.00

13.50

30

13.50.... j’o’.OO

13.50

54.00

54.00

Week

Ending

ICC

1108658

Arnold, John Anthony

08/04/2019 05-Housekeeping

1-Hskp AM skilled

• I

' i0.45

120

Total

HU1-B-33-B

■

1108658

Arnold, John Anthony

0.00

Printed on 9/11/2019 2:29:57 PM