State of North Carolina North Carolina Industrial Commission TA - P ETITION TO S UE AS AN I NDIGENT P ERSON IC File # v. Plaintiff's Name Defendant's Name 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 Ind ustrial Commission. 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 Fa milies w ith Dependent Children (AFDC). Supplemental Security Income (SSI) I am a prison inmate. A Department of Corrections report is attached showing 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 financially unable to advance the costs of filing this actio n or appeal. (An affidavit listing my income and expenses is attached) Sworn and subscribed to before me Signatur e Date Name of Applicant (Please Print) Title of Person Authorized to Administer Oaths SEAL Signature of Applicant Date Commission Expires Date ORDER Pursuant to N.C.G.S. 247 1 - 110 and 11 NCAC 23 B .0103 , the undersigned has determined that this action is not frivolous. frivolous . (applies only to claims brought by inmates) Based upon the Af fidavit appearing above, it is ORDERED that: The applicant is authorized to bring suit as an indigent . The petition is denied. The action is dismissed. Commissioner Deputy Commissioner Signature Date E - mail Affidavit to: dockets@ic.nc.gov OR Mail Affidavit to: N.C. Industrial Commission Docket Section 12 36 Mail Service Center Raleigh, NC 27699 - 12 36 American LegalNet, Inc. www.FormsWorkFlow.com