Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) — Alvarado v. CA Unemployment Ins. Appeals Board (CUIAB) (Dkt. 2, E.D. Cal.)

Summary

An application to proceed in district court without prepaying fees or costs, on Form AO 239 (Rev. 01/15), Long Form, filed 12/29/23 as Document 2 in Case 2:23-cv-03041-TLN-CSK in the U.S. District Court for the Eastern District of California. The applicant, a plaintiff, declares under penalty of perjury an inability to pay the costs of the proceedings. Many of the handwritten entries for income, employment, assets and dependents read N/A. The applicant answers Yes to expecting major changes to monthly income or expenses in the next 12 months, writing PUA, and Yes to spending money on expenses or attorney fees for the lawsuit.

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Case 2:23-cv-03041-TLN-CSK Document2 _ Filed 12/29/23. Page1of6
Page lof 5
AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) : | | L E D ©
UNITED STATES DISTRICT COURT ¢¢ 239 1023
for the
'S. ASTRICT COURT
EASTERN istry OF CALIFORNIA
LANGE DELON Ak VARAD © ) Dero ERA

) Civil Action No.

Defendant/Respondent
APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS

Affidavit in Support of the Application Instructions

Complete all questions in this application and then sign it.
Do not leave any blanks: if the answer to a question is “0,”
“none,” or “not applicable (N/A),” write that response. If
you need more space to answer a question or to explain your
answer, attach a separate sheet of paper identified with your
name, your case's docket number, and the question number.

1 am a plaintiff or petitioner in this case and declare
that I am unable to pay the costs of these proceedings
and that I am entitled to the relief requested. I declare
under penalty of perjury that the information below is
true and understand that a false statement may result in
a dismissal of my claims.

Signed: tt Date: /Z- Ch - Z3
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 income Income amount expected
amount during the past 12 next month
months
You Spouse You Spouse
Employment $_o $ WA $ ce $ Ni 4
Self-employment $ f
Income from real property (such as rental income)
Interest and dividends AVA Alle
$ => $ $e $
AYA
Gifts f
LAO $s $ Yee $ N/A
Child support $ oe $ Hi, ‘li $ eo $ A. lp
Case 2:23-cv-03041-TLN-CSK Document 2

AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)

Filed 12/29/23

Page 2

of 6

Page 2 of 5

Retirement (such as social security, pensions, annuities, . 1
insurance) $ o> $ A / A $ N [A $ WV bo
Disability (such as social security, insurance payments) $ $ ,
Unemployment payments
Public-assistance (such as welfare) ; r
Other (specify): _ f ’ ;
$.—S- $ NIA $ NLA $ N/A
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
monthly pa
$
$
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

counts or in’any other financial institution.

Financial institution Type of account Amount you have Amount your
NIA NLA At spouse has
Md Nt 8 At s wht

If you are a prisoner, 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.
Case 2:23-cv-03041-TLN-CSK Document 2

AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)

Page 3 of 5

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

household furnishings.

Assets owned by you or your spouse

Home (Value)

8 NIA

Other real estate (Value)

Motor vehicle #/ (Value)

Make and year:

Model:

Registration #:

Motor vehicle #2 (Value)

Make and year:

Model:

Registration #:

Other assets (Value)

Other assets (Value) $ Wy. 1A
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 spouse
money
EMPWOY MENT $
$ $
$ $
7. State the persons who rely on you or your spouse for support.
Name (or, if under 18, initials only) Relationship Age

MA

N/A

MN
Case 2:23-cv-03041-TLN-CSK Document2_ Filed 12/29/23. Page5of6
Page 5 of 5

AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)

Regular expenses for operation of business, profession, or farm (attagh detailed
Statement) Soares Hy. ve Io} 6bC $ N/A $ NIA

Total monthly expenses: $/FO~- 0.0018 yl /A 0.00

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 1 No If yes, describe on an attached sheet. P UA

10. Have you spent — or will you be spending —- any money for expenses or attorney fees in conjunction with this
lawsuit? & Yes (CINo

If yes, how much? $ UNK ANOLON

11. Provide any other information that will help explain why you cannot pay the costs of these proceedings.

12. Identify the city and state of your legal residence.
WHEATKANDS CALIFORNIA

Your daytime phone number: TIS~8 F9- AbZBX

Your age: 5 / Your years of schooling: CoNWZ/NVUEING EDUCATION


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