8/9/2019 Kathryn Sorrentino Financial Affidavit

1/5

lFD

UNITED STATES DISTRICT COt. ,.

DISTRICT OF

MM\ \ A 8:

23

MOTION FOR LEAVE TO PROCEED IN

PURSUANT TO 28 U.S.C.

1915

Gifh

'$ ( 2? @

8/9/2019 Kathryn Sorrentino Financial Affidavit

2/5

UNITED STATES

DISTRICT COURT

DISTRICT OF CONNECTICUT

FINANCIAL AFFIDAVIT IN SUPPORT

OF

MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

PURSUANT

TO

28 U.S.C. 1915

>

Plaintiff(s),

v.

Case No.

IJ\ 0

vI( :r Wv . J ,

Defendant(s}. .

ihc\N{d

v.p.

\ y

.:11 .

cA(.:J(IIccty

CouV

G:?

8/9/2019 Kathryn Sorrentino Financial Affidavit

3/5

Owed to:

Total:

5 S3

J

na..

.1Jb

13a.V\\C p t

AMe r k { ... ( \ \11

Montffiy payment

'2(

8/9/2019 Kathryn Sorrentino Financial Affidavit

4/5

EDUC TION

Please indicate the highest level of formal education you have completed:

EMPLOYMENT

If employed at present, complete the following:

Name of employer: ----'-''''-+-'IA-- --

Address of employer:

How long employed by present employer:

Income: Monthly Weekly ______ __

If self-employed state weekly wages:

What is the nature

of

your employment?

If unemployed at present, complete the following:

I have been unemployed since the day of e t : 1 19 )..

The name

of

my last employer: t-lo.V r4 e.f- L

VI .

Addre s:

,MR Ln 16 ( '?-

N I

Qt ......-\--

I

n

-e..s

's

Telephone : ( ) - OtA.f--- O- \

8/9/2019 Kathryn Sorrentino Financial Affidavit

5/5

Estir, ,18ted

monthly expenditure on clothing:

Total amount o monthly obligations:

t .-f-I

L :[

:,\:.wk=--

5 L

Other information pert inent to financial status: Include stocks, bonds, savings bonds,

interests in trusts either owned or jointly owned):

PREVIOUS LITIGATION

If you have ever filed a case in this district, provide the following information for each

case you have filed_ If you need additional space, please continue on a separate sheet.

Case Number

Case Caption Disposition o Case

1_

2.

.

_

4.

5.

Original Signature o Affiant

DECLARATION UNDER PENALTY OF PERJURY

I declare under penalty o perjury under the laws o the United-States o America that

the foregoing is true and correct to the best

o my

knowledge and belief.

Original Signature o Affiant

Rev.1211/11

5

!"#$ &'(&)*+),,&-.)//0 12*34$56 7 89:$; ,&