EX PARTE APPLICATION FOR RELIEF FROM COSTS; DECLARATION; ORDER TWO-SIDED FORM Form #3DC13 IN THE DISTRICT COURT OF THE THIRD CIRCUIT ______________________________ DIVISION STATE OF HAWAI‘I Plaintiff(s) Reserved for Court Use Civil No. Defendant(s) Filing Party(ies)/Filing Party(ies)' Attorney (Name, Attorney Number, Firm Name (if applicable), Address, Telephone and Facsimile Numbers) EX PARTE APPLICATION FOR RELIEF FROM COSTS (From each Requesting Party) Pursuant to Hawai‘i Revised Statutes §607-3, the Filing Party in the above-entitled case applies for waiver to prepay fees, costs or give security because said Party is unable to pay the costs of this suit and provide for said Party's necessities in life. 1. Are you presently employed? Yes G a. If the answer is "yes", < State the amount of your monthly salary/wages: $ < Name and address of your employer: b. No G If the answer is "no", < State the date of last employment: < Name and address of your former employer: < Amount of monthly salary and wages you received: $ 2. Have you received within the past twelve months any money from any of the following sources? a. Business, profession or from self-employment? No G Yes G d. Gifts or inheritances? Yes G No G b. Rent payments, interest or dividends? Yes G No G e. Any other family income? Yes G No G c. Pensions, annuities or life insurance payments? Yes G No G f. Any other sources? Yes G No G If the answer is "yes," describe each source of money and state the amount received from each during the past twelve months. (continued on reverse side) COSTRELF.2X (Amended 4/18/97)v SEE REVERSE SIDE 3D-P-266 American LegalNet, Inc. www.FormsWorkflow.com EX PARTE APPLICATION FOR RELIEF FROM COSTS (continued) 3. Do you have any cash or money in a checking or savings account? (Include any funds in prison accounts.) Yes G No G If the answer is "yes," state the total value of the items owned. 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes G No G If the answer is "yes," describe the total value of the items owned. 5. List the persons who are dependent upon you for support. State your relationship to those persons and indicate how much you contribute toward their support. The undersigned requests that this Application be granted for the reasons stated above. Signature of Filing Party/Filing Party's Attorney: Date: Print/Type Name: DECLARATION I have read this Application, know the contents and verify that the statements are true to my personal knowledge and belief. I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF HAWAI‘I THAT THE ABOVE IS TRUE AND CORRECT. Signature of Declarant: Date: Print/Type Name: ORDER Good cause having been shown, IT IS ORDERED that the Party applying for relief from cost in this case shall be permitted to proceed in the above-entitled action in forma pauperis, all costs and fees being waived for the duration of this case (excluding Sheriff(s)' fees). Date: Judge of the above-entitled Court In accordance with the Americans with Disabilities Act if you require an accommodation for your disability, please contact the ADA Coordinator at PHONE NO. 934-5788, FAX 935-1959, or TTY 961-7525 at least ten (10) working days in advance of your hearing or appointment date. 3D-P-266 American LegalNet, Inc. www.FormsWorkflow.com