Petition for Writ of Certiorari — Cassandra McGuire, Petitioner v. Highmark Holdings, et al.

In th^Stijleeme CSdrt.?jf'tl?e*Unifed States

f

WSSawif

Plaintiff, Cassandra McGuire, Pro Se

V.

Supreme Court, U.S.

FILED

APR 2 H 2023

Defendant, Robbie King and Glenda Shamwellj 0FFICEqf the clerk

Respondents Attorney.Ronna Kinsella Glassman Wyatt and Tuttle.

On Petition for a Writ of Certiorari to the

United States Court of Appeals for the Sixth Circuit

Federal Case 3:19-cv-00902; Appeals Docket No. 22-5881

Motion to Proceed Forma Pauperis in Regards to Petition for a Writ of

Certiorari to the

United States Court of Appeals for the Sixth Circuit

27 E. Chandler Ave. Apt. B

Evansville, IN 47713

615-482-6897

caveritt2000@yahoo.com

AFFIDAVIT OR DECLARATION

INx SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

^3Sl3rNC^{viffJ f \

ioner 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

Amount expected

next month

Spouse

You

Spouse

Employment

$

$.

$.

Self-employment

$

$.

$.

Income from real property

(such as rental income)

$.

$.

$.

$.

Interest and dividends

$.

$.

$.

$.

Gifts

$.

$.

$.

$.

Alimony

$.

$_1

$.

$.

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):

$.

$.

$.

$.

$<.

$.

$.

$.

Total monthly income:

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

is before taxes or other deductions.)

Employer

Address

(—'

_____

Dates of

Employment

Gross monthly pay

$

$.

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

Dates of

Employment

Gross monthly pay

$.

$.

$.

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.

Type of account (e.g., checking or savings)

PAv

Amount you have

_____ _________ $

co

$

$.

Amount your spouse has

$

y

$

$.

5. 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

A

,

,

Year, make & model ,-JlxXo WfgL

Value

900-0

□ Other real estate

Value________

Motor Vehicle #2

$0ip

Year, make & model

tyiuL

Value 1560.0 ^

P

lo*

□ Other assets

Description _

Value_____

c/col'fc

//

ber^ CJpi^Clf

\ul

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

amount owed.

Person owing you or

your spouse^noney

Amount owed to you

Amount owed

t

your spouse

7. State the persons who rely on you or your spouse for support. For minor children, list initials

instead of names (e.g. “J.S.” instead of “John Smith”).

Name

( .nooi

(Ur.

Relationship

7Tr

ll*UI

Age

fvt/pKi^

SUlTY

lH

U

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.

You

Your spouse

Rent or home-mortgage payment

(include lot rented for mobile home)

Are real estate taxes included? □ Yes Q?No

Is property insurance included? □ Yes ^No

$.

ju--Utilities (electricity, heating fuel,

water, sewer, and telephone)

Home maintenance (repairs and upkeep)

Food

* 4

Clothing

$.

$.

Laundry and dry-cleaning

$.

Medical and dental expenses

$.

2©

30 ?

$.

i

*

t

%

'4

f

Y<hi

Transportation (not including motor vehicle payments)

Your spouse

$—/i/JO 6/iv-— $.

Recreation, entertainment, newspapers, magazines, etc.

/

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

||£,.« I55V'»

Homeowner’s or renter’s

Life

$.

$.

Health

$.

$.

Motor Vehicle

$.

$.

>MU£

«__i

Other:

[Ywrt/ va

-Thi

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

(specify): duo

Installment payments

£ofrmtW'/y $ c*5501)

.TVv^i

$.

Frcuol

'Vb

Motor Vehicle

$.

$.

Credit card(s)

$.

$.

Department store(s)

$.

$.

$.

$.

Other:

C <\lb V-

Alimony, maintenance, and support paid to otheire

,

$.

kltfhsud/pisfjpftd (Y\o*\.

-JD jf»

Regular expenses for operation of business, profession, '

or farm (attach detailed statement)

Other (specify):

At^f-Aor^

Qr~|- uje^r .

Total monthly expenses:

$.

$.

$.

$.

$.

$

*

*

?

Mao or

x 40.0b Cjfto Ca0ihv^

0

0

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

liabilities during the next 12 months?

UAtrvi^n ,

□ Yes

DNo

If yes, describe on an attached sheet.

IS,

Ca (jAf <X/t

j

(nn

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

o

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

No

If yes, how much?

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

/

r>

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

IP hcu^ \SiiGm)fL iflyAoaj £(%\2

^ /j?S\ Od

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

Executed on:

20^3

(Signature)