Petition for Writ of Certiorari — Raymond Brown, Petitioner v. Pennsylvania

i

No.

-5803

IN THE

SUPREME COURT OF THE UNITED STATES

_ — PETITIONER

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(Your Name)

VS.

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14A

— RESPONDENT(S)

fib AVETEZhM

MOTION FOR LEAVE TO PROCEED^ 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.

K4 Petitioner has previously been granted leave to proceed in forma pauperis

in the following court(s):

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[ ] 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.

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(Signature)

CAUTION: NOT TO BE USED FOR

IDENTIFICATION PURPOSES

THIS IS AN IMPORTANT RECORD

SAFEGUARD IT.

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ANY ALTERATIONS IN SHADED AREAS

RENDER FORM VOID

0F relEASE or discharge from active duty

This Report Contains Information Subject to the Privacy Act of 1974. As A

1. NAME (Last. First, Middle)

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ARMY/ARNGUS

4a. GRADE, RATE OR RANK. ' I * HAY GRADE,:,

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* DATE OF BIRTh/^^

6584 WALNUT PARK DR

PHILADELPHIA PENNSYLVANIA 19120-0000

i 8a. LAST DUTY ASSIGNMENT AND MAJOR COMMAND

FORT LEE, VA 23801-5152

: 9. COMMAND TO WHICH TRANSFERRED

iSEE SLOCK 18

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10. SGLI COVERAGE)

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|11. PRIMARY SPECIALTY (List number, title and years and months in

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»■ DATE ENTERED AD THIS PERIOD

b. SEPARATION DATE THIS PERIOD

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6. RESERVE OBLIGATION TERMINATION DATE

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AFFIDAVIT OR DECLARATION

IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

I,

1__ , 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

You

Amount expected

next month

Spouse

You

Sipouse

a

$ O

$.

$ e>

$.

Employment

$.

CP

Self-employment

$.

G?

Income from real property

(such as rental income)

$.

$.

$ CP

$.

Interest and dividends

$___ S

$.

$__ o

$_o

Gifts

$.

5°

$.

o

$.

Alimony

$.

$.

o

$.

$.

(9

$.

Child Support

6

. $___ ®

to

$.

&

$.

&

Retirement (such as social

security, pensions,

annuities, insurance)

$.

Disability (such as social

security, insurance payments)

$

CP

$.

O

$.

Unemployment payments

$.

CP

$.

CP

$.

Public-assistance

(such as welfare)

$.

CP

$.

CP

$.

Other (specify): u

$.

Total monthly income:

$.

Hbckxp $_

$ tk 6 Cpb

*

$

o

C>

o

$.

$.

CP

$.

CP

»

0

$ o

$___

O

$.

$.

o

$.

C>

o

G

(3

(5

$.

x5

$.

G

<5

$.

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

is before taxes or other deductions.)

Employer

Address

L

Dates of

Employment

Gross monthly pay

LM

^11^\

$_

$.

$.

y/sx

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

d-L

HLA

Dates of

Employment

$

yin

/ /r

Gross monthly pay

s

juJ/1

J Lj/x

J

✓)

l/J

? \J

l

4. How much cash do you and your spouse have? $_______ K( / /X____________

Below, state any money you or your spouse have in bank accounts or in any other financial

institution.

Financial institution

m

/

Type of account

n

kj / /}

ji//''

Amount you have

Amount your spouse has

$

$

$.

$.

$

$

t,//7

hi/

UL

n"

t /

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

and ordinary household furnishings.

□ Home

Value

□ Other real estate

Value

Y\ 61^-'

□ Motor Vehicle #1

Year, make & model

Value

6 ^

□ Motor Vehicle #2

Year, make & model

Value

v\ 6

□ Other assets

Description

Value

k\ O f

Vi /’.Us

Kio>-<r

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

amount owed.

Person owing you or

your spouse money

Mm

Amount owed to you

Amount owed to your spouse

$.

$.

$.

$.

kt / A

'Mr

$.

ul/X

/' U

Is I1 Z is

$.

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

Name

l /

LA

n (/*-

Relationship

a

/

Age

La

l / /A

/1 // y

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

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

annually to show the monthly rate.

Rent or home-mortgage payment

(include lot rented for mobile home)

Are real estate taxes included? □ Yes Q^No

Is property insurance included? □ Yes Q<No

You

Your spouse

$.

$.

(S

/

Utilities (electricity, heating fuel,

water, sewer, and telephone)

$.

Home maintenance (repairs and upkeep)

$.

Food

$.

O

$.

i> i *e>

(o

Clothing

6

Z5

o

$. 6

$.

» 6

Laundry and dry-cleaning

Medical and dental expenses

$.

$.

$ Qr

$.

Your spouse

You

Transportation (not including motor vehicle payments)

$.

d

$.

Recreation, entertainment, newspapers, magazines, etc.

$.

4o

$.

£S

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

O

Homeowner’s or renter’s

$.

Life

$_

Health

$.

Motor Vehicle

$.

o

o

$.

o

uj/l

Other:

$.

$.

$.

$.

o

o

o

$.

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

$.

o

$.

Motor Vehicle

$.

O

$.

Credit card(s)

. $.

O

$.

$.

o

$.

$.

6

$.

Alimony, maintenance, and support paid to others

$.

D

$.

Regular expenses for operation of business, profession,

or farm (attach detailed statement)

$.

(D

n\pr

$.

u(/3-

(specify):

is

Installment payments

Department store(s)

Other:

Other (specify):

uLA

Total monthly expenses:

$.

&

(a

6

€>

(3

o

% °

$■

&

‘

*,

*

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

liabilities during the next 12 months?

6{No

□ Yes

If yes, describe on an attached sheet.

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

with this case, including the completion of this form? □ Yes ^02No

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

o

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.

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

Executed on:

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(Signature)