Motion for Leave to Appeal In Forma Pauperis by David Staveley. Responses due by 11/29/2021 — USA v. Staveley (Dkt. 66, D.R.I. No. 1:20-mj-00034, docketed in No. 1:20-cr-00074)

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Case 1:20-cr-00074-WES-LDA Document66- Filed 11/15/21 Page 1 of 4 PagelD #:
533

AFFIDAVIT ACCOMPANYING MOTION
gtk SuRNSSTON TO APPEAL IN FORMA PAUPERIS

District Court No. /:ap -er~ ooggy- ms M2 LDA~!
Appeal No, 3/7 - 4% 42

Affidavit in Support of Motion Instructions

I swear or affirm under penalty of perjury that, Complete all questions in this application and
because of my poverty, I cannot prepay the docket then sign it. Do not leave any blanks: if the answer
fees of my appeal or post a bond for them. I believe to a question is “0,” “none,” or “not applicable

I am entitled to redress. I swear or affirm under (N/A),” write in that response. If you need more
penalty of perjury under United States laws that my space to answer a question or to explain your
answers on this form are true and correct. (28 answer, attach a separate sheet of paper identified
U.S.C. § 1746; 18 U.S.C. § 1621.) with your name, your case’s docket number, and

the question number.

Signed: \ YG vd (Tae a Date: // / o) d- [

My issues on appeal are:
OEvcthahve Counsel
—_——> CD 3553 Voletvon Cure nee
5 at Scwteacteg :
0) Us¥ecr e+ rorvt

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.

[i Tufermation wt Lill fof prea dd Cv const ol red

Income source Average monthly Amount expected next
amount during the past | month
12 months
You Spouse You Spouse
Employment $ 6 $ $6 $
Self-employment $8 $ $ © $
Income from real property (such as rental income) | $ 4 $ $ $
Interest and dividends $ @ $ ANA |$ 6 $ th
Gifts $ 8 $ | $ $
Alimony $ 0 $ $ © $
Child support $4 $ _ $
Retirement (such as social security, pensions, $ $ $ $
annuities, insurance) v ©
Disability (such as social security, insurance $ $ $ $
payments) Q ®
Unemployment payments $ ~ $ $ 8 $

i
Case 1:20-cr-00074-WES-LDA Document66- Filed 11/15/21 Page 2 of 4 PagelD #:

534
Public-assistance (such as welfare) $ & $ $ © $ /
Other (specify): $ 0 $ $ © $ (
Total monthly income: $0 $o $0 $0
2. List your 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
cy monthly pay
Comeles Kodeo | Wercerter, whit (fra $flojr0 |$_ 390
$
$
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
wll Ze $
fF! $
$
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 jinancial
institution.
Financial Institution Type of Account Amount you Amount your
have spouse has
a $ $
$ $

If you are a prisoner seeking to appeal a judgment in a civil action or proceeding, you must attach a
statement certified by the appropriate institutional officer showing all receipts, expenditures, and
balances during the last six months in your institutional accounts. If you have multiple accounts,
perhaps because you have been in multiple institutions, attach one certified statement of each account.

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

Home Other real estate Motor vehicle #1
(Value) $ (Value) $ (Value) $ ae)
:" Make and year: 7
C O Model: /
Registration #:

Case 1:20-cr-00074-WES-LDA Document 66

Filed 11/15/21

Page 3 of 4 PagelD #:

535
Motor vehicle #2 Other assets Other assets
(Value) $ iS) (Value) $ (Value) $
Make and year: 5
Model: a v O
Registration #:_//
6. State every person, business, or organization owing you or your spouse money, and the amount
owed,
Person owing you or your spouse Amount owed to you Amount owed to your
money spouse
Ajo" $ WJ] V1 $
t $ $
$ $
7. State the persons who rely on you or your spouse for support.
Name [or, if under 18, initials only] Relationship Age
Fodith Coubyrn Wiofle « ol
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, semiannually, 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? [X] Yes [ ] No / S 60
Is property insurance included? [ ] Yes [ ]No
Utilities (electricity, heating fuel, water, sewer, and telephone) $ 78 o $
Home maintenance (repairs and upkeep) $ $
Food $ 2070 [8
Clothing $ 50 $
Laundry and dry-cleaning $ oo $
Medical and dental expenses $ — $ ‘
Transportation (not including motor vehicle payments) $ 50 $ .) | [- :
Recreation, entertainment, newspapers, magazines, etc. $0 $ fall ia

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

Homeowner’s or renters: ¢ (OD $
Life: $= $
Health: So $
Motor vehicle: Ge $
Other: $on $
Taxes (not deducted from wages or included in mortgage payments) $ $

(specify):

Case 1:20-cr-00074-WES-LDA Document66- Filed 11/15/21 Page 4 of 4 PagelD #:

536

Installment payments
Motor vehicle:
Credit card (name):
Department store (name):
Other:

Alimony, maintenance, and support paid to others

Regular expenses for operation of business, profession, or farm (attach
detailed statement)

TBF F194 1091
FAIA SFA

Other (specify): $

VEN PEAT

$

Total monthly expenses: $o Qeee [go

10.

11.

12,

TFrecrv cr rated — ofleir VIEW pegs a a mM ont ily CX PHAIE SL On”. her GA W.

Do you expect any major changes to your monthly income or expenses or in your assets or
liabilities during the next 12 months?

{ ] Yes XI No If yes, describe on an attached sheet.

Have you spent — or will you be spending — any money for expenses or attorney fees in
connection with this lawsuit?

[ ] Yes M1 No If yes, how much?

Provide any other information that will help explain why you cannot pay the docket fees for your
appeal. ' j
PP Pe eseatly iv carcecated

State the city and state of your legal residence: py) rae f P Pa sa hu J? la f
Your daytime phone number: (79 _26Y- & 275 0 .

Your age: _3_ ZL. Your years of schooling: High Shodf fone Co eg €

Last four digits of your social-security number: rfl"

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