Dis State of Minnesota Court County of Washington Judicial District: TENTH Court File Number: Case Type: Civil Constitutionality os ‘S282 Tax Forfeiture,Injunctive Relief Jury Demand Cheryl Hilyar, radars eeenaeercenn ree : Affidavit for Proceeding a In Forma Pauperis (Minn, Stat. §563.01) State of et al, Washington Count rd and thers ‘DetenaatRespondet 1. Trequest a court order waiving court fees and costs. believe that I have valid reasons for pursuing this: (check one) Civil 1 Family 0 Probate action. 2. Tam a party in this action and in good faith I request an Order to proceed in forma pauperis. 3. (1 Lam receiving public assistance under one or more of the following programs: © SSI and/or MSA (The Supplemental Security Income and Minnesota Supplemental Assistance Programs); MFIP (Minnesota Family Investment Program); Food Stamps; Gezieral Assistance or Work Readiness; Medical Assistance or General Assistance; Medical Care; Energy Assistance; and/or Other (specify) 3. Cl Lam represented by attomey on behalf of a civil legal services program or volunteer attomey program, based on indigency. 4, (1 My annual family income before taxes is $ which is less than 125% of the Federal Poverty Line for my family size ‘members. Note: See the Court Administrator's office for a current poverty line schedule. Ifyou checked any of boxes 2 through 4 above, skip 5 and sign this document in the presence of a notary public. Telephone UoSD= 388 Hon5. Ci Leannot support my family and myself and also pay court fees and costs. Ifyou check this box, you must complete the following financial statement. (tems A-1) . There are minor child(ren) residing with me. |. My net (take home) monthly income is $ A B. C. The source of my monthly income is D. E. EB . Lpay §, per month in childcare or support. . Tpay S. per month for rent/mortgage payment. . Lown the following property: 1. Cash 8 = 2. Checking, savings and credit union acets s Cars, other vebiles (list make, year and equity value (market value minus ‘unpaid loans) for each) sgn ce eee rece gfe eee eecrerrrreceeesevveeeeeoe 8 Bese cee een eeeeeeeeeeeee nineeeeeees 4, Real Estate 8 ‘5. Other personal property (jewelry, stocks, bonds, ete list separately) See Gee eee ee Se cieeeuee rere Secession eee 8 G. [am presently $ in debt. H, Lam unable to pay the costs and expenses of this proceeding or to give security for such costs and expenses. L Other factors which support this are (explain ‘unusual medical expenses, emergencies or other circumstances to help the Judge understand your situation): administrator) Sworn/affirmed before me this Telephone: