UNITED STATES COURT OF APPEALS DISTRICT OF COLUMBIA CIRCUIT 333 Constitution Avenue, NW Washington, DC 20001-2866 Phone: 202-216-7000 | Facsimile: 202-219-8530 USCA No. MOTION FOR WAIVER OF FEES , declare that because of my poverty I am unable to prepay the costs of retrieval and photocopying the requested documents in the above case. My affidavit is attached. I believe I am entitled to these documents because: (Provide a statement of the reasons you wish to present to the Court.) I, Signature Name of Requester Address Submit original to: Clerk U.S. Court of Appeals for the D.C. Circuit U.S. Courthouse, Room 5523 Washington, D.C. 20001 USCA Form 32 August 2009 (REVISED) American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES COURT OF APPEALS FOR THE DISTRICT OF COLUMBIA CIRCUIT AFFIDAVIT IN SUPPORT OF MOTION TO WAIVE FEES I swear (affirm) that the responses which I make below to the questions concerning my ability to pay the costs as stated in the motion are true. 1. Are you presently employed? a. Yes No If the answer is "yes", state the amount of your salary or wages per month and give the name and address of your employer. (List both gross and net salary.) Gross salary and wages per month: $ Net salary and wages per month: $ Employer Name: Address: b. If the answer is "no", state the date of your last employment and the amount of the salary and wages per month which you received. Date of last employment: Salary and wages per month: $ 2. Have your received within the past twelve months any income or property from any of the following sources? a. Business, profession or other form of self-employment? b. Rent payments, interest, or dividends? c. Pensions, annuities or life insurance policies? d. Gifts or inheritances? e. Any other sources? Yes Yes Yes Yes Yes No No No No No If the answer to any of the above is "yes", describe each source of money and state the amount received from each during the past 12 months. Source: Source: Source: Source: Source: USCA Form 32 August 2009 (REVISED) American LegalNet, Inc. www.FormsWorkFlow.com Amount: $ Amount: $ Amount: $ Amount: $ Amount: $ 3. Do you own any cash or checking or savings accounts (including joint accounts)? a. If the answer is "yes," state the total value of the items owned: $ Yes No 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? a. If the answer is "yes," describe the property and state its approximate value. Approximate value: $ Yes No 5. List any persons who are dependent upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support. Dependent: Relationship: Dependent: Relationship: Dependent: Relationship: Dependent: Relationship: Dependent: Relationship: Amount: $ Amount: $ Amount: $ Amount: $ Amount: $ I declare under penalty of perjury that the forgoing is true and correct. Signature of applicant Name of Requester Address Executed on: USCA Form 53b August 2009 (REVISED) American LegalNet, Inc. www.FormsWorkFlow.com