State of North Carolina North Carolina Industrial Commission PETITION TO APPEAL AS AN INDIGENT PERSON IC File # Plaintiffs Name Defendants Name Address Address City State Zip City State Zi p AFFIDAVIT As the individual plaintiff in the above-entitled action, I affirm that I am financially unable to advance the required costs for the prosecution of this action before the North Carolina Court of Appeals. Therefore, I now petition the Industrial Commission for an order allowing me to bring suit in this action as an indigent. Check one or more of the boxes below as applicable I am presently a recipient of Food Stamps Aid to Families With Dependent Children (AFDC). Supplemental Security Income (SSI) I am a prison inmate. A Department of Corrections report is attached sh owing deposits, withdrawals, and balances in my prison trust account during the last six months. Although I am not a recipient of food stamps, AFDC, or SSI, I am financi ally unable to advance the costs of filing this action or appeal. Sworn and subscribed to before me Signature Date Name of Applicant (Please Print) Title of Person Authorized to Administer Oaths Signature of Applicant Date SEA L Date Commission Expires ORDER Based upon the Affidavit appearing above, it is ORDERED that: The applicant is authorized to bring suit as an indigent The petition is denied. Commissioner Deputy Commissioner Executive Secretary Signature Date American LegalNet, Inc. www.USCourtForms.com